Chronic subdural haematoma — a comparison of two different treatment modalities

Summary Burr-hole craniotomy (BHC) and closed-system drainage undoubtedly is currently the most accepted treatment offered in chronic subdural haematoma (CSDH). Although twist-drill trephination (TDT) techniques have been available for years, now a special subdural catheter kit has been launched for treatment of CSDH. In a prospective study, 33 patients with 36 CSDH were treated with a 5-mm TDT regimen and insertion of a CORDIS subdural catheter (CORDIS Corp., Miami, USA). The results are compared with a consecutive series of 33 patients treated previously with an 11-mm BHC and closed-system drainage for 40 CSDH: Recurrence and persistence rate of CSDH treated with TDT necessitating a second intervention was 18.1%, no further surgical intervention was necessary. In BHC treated patients, 33.3% of haematomas had to be reoperated on, another 6.0% had to be re-operated on a third time. Infection rate in BHC treated patients was 18.1% as compared with a 0% infection rate in patients treated with the TDT technique. Mortality rate for the BHC method was 9.0% as compared with 6.0% in the TDT treatment regimen.Significantly better clinical results are achieved using the TDT technique with insertion of a special subdural catheter, making this procedure superior to the BHC regimen.     

Spontaneous evolution of posttraumatic subdural hygroma into chronic subdural haematoma

Summary Thirteen of 145 patients with post-traumatic subdural hygroma (SDHy) developed chronic subdural haematoma (CSDH) at the involved site over a period of 6 years. CSDHs were found at the site of SDHys with no history of further head injury at a mean interval of 56 days. It appeared that these 13 patients did not have any distinguishing clinical features early on. Old age and brain atrophy on CT scans do not seem to be reasonable causative factors in the evolution of SDHy into CSDH. Initial enlargement of subdural accumulations at an early stage of SDHy and a subsequent increase in density at a later stage may point to the development of CSDH from SDHy in some instances. Ten of these 13 CSDH cases underwent surgical drainage, and the remaining 3 cases received no specific management. All resolved completely. The prognosis was good in all patients. The possible mechanism for the evolution of SDHy into CSDH is discussed.     

A rare case of chronic subdural haematoma presenting with paraparesis: A case report and review of literature

Objectives

To report a rare case of spontaneous chronic subdural haematoma presenting with paraparesis and to highlight that subdural haematoma as one of the differential diagnoses for unexplained paraparesis.

Summary of background data

Chronic subdural haematoma is common in elderly people usually presenting with altered mental status, monoplegia, headache and seizure. But spontaneous chronic subdural haematoma resulting in paraparesis is not reported in the literature.

Methods

A 58-year-old male patient presented with weakness of bilateral lower limbs and retention of urine and constipation. Patient was thoroughly evaluated and analysed.

Conclusion

Spontaneous chronic subdural haematoma should be considered as one of the deferential diagnosis for paraparesis in elderly.Abbreviations: CSDH, chronic subdural haematoma; MRI, magnetic resonance imaging; ICBF, intracranial blood flow     

Risk factors for the occurrence of chronic subdural haematomas after neurosurgical procedures

Summary ¶Chronic subdural haematoma (CSDH) is a rare clinical complication of neurosurgical procedures. CSDH occurs sporadically after aneurysm clipping surgery and revascularisation surgery but the risk factors are not known. The present study reviewed 6613 consecutive neurosurgical procedures performed from January 1987 to July 2001, and identified 621 cases of CSDH. Fifty of these 621 cases had a past history of neurological disorders treated by neurosurgery. This study evaluated these 50 cases in order to elucidate the clinical and radiological characteristics of CSDH after neurosurgery and to investigate the etiology for identifying in the risk factors of CSDH as a postoperative complication. The incidence of CSDH after neurosurgery was 0.8% (50/6613). Twenty-seven of the 50 patients with a past history of neurosurgery had undergone aneurysm clipping surgery. The incidence after clipping surgery was 2.4%. Twelve of these 27 cases also underwent ventriculoperitoneal shunting. Three patients had postoperative CSDH after arachnoid cyst opening and/or shunting. The incidence was highest at 7.5%. Three patients had postoperative CSDH after brain tumour surgery. The incidence was low at 0.4%. However, the ventricular cerebrospinal fluid (CSF) space was opened during tumour removal in 2 of these 3 patients.Communication of the subarachnoid space to the subdural space is considered to be one of the causative factors and excessive CSF shunting facilitates formation of CSDH after neurological surgery. Repair of arachnoid tearing during neurosurgery and avoidance of excessive CSF shunting may reduce the risk of CSDH after neurosurgery.Published online May 19, 2003     

No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma

Introduction

Neurosurgical trainees should achieve competency in chronic subdural haematoma (CSDH) drainage at an early stage in training. The effect of surgeon seniority on recurrence following surgical drainage of CSDH was examined.

Methods

All CSDH cases performed at St George’s Hospital in London between March 2009 and March 2012 were analysed. Recurrence was defined as clinical deterioration with computed tomography evidence of CSDH requiring reoperation within six months. The following risk factors were considered: seniority of primary and supervising surgeons, timing of surgery (working hours, outside working hours), patient related factors (age, antiplatelets, warfarin) and operative factors (general vs local anaesthesia, burr holes vs craniotomy, drain use). For recurrent cases, we examined the distance of the cranial opening from the thickest part of the CSDH.

Results

A total of 239 patients (median age: 79 years, range: 33–98 years) had 275 CSDH drainage operations. The overall recurrence rate was 13.1%. The median time between the initial procedure and reoperation was 16 days (range: 1–161 days). The only statistically significant risk factor for recurrence was antiplatelets (odds ratio: 2.62, 95% confidence interval: 1.13–6.10, p<0.05). Warfarin, grade of surgeon, timing of surgery, type of anaesthesia, type of operation and use of drains were not significant risk factors. In 26% of recurrent CSDH cases, the burr holes or craniotomy flaps were placed with borderline accuracy.

Conclusions

CSDH drainage is a suitable case for neurosurgical trainees to perform without increasing the chance of recurrence.     

Surgical complications of chronic subdural haematoma: A 5‐year audit

Objective: To review the outcome of surgical treatment for chronic subdural haematoma (CSDH) at a local neurosurgical centre, with emphasis on major treatment‐related complications. Method: A total of 108 patients received operations for chronic subdural haematoma at the University of Hong Kong Medical Centre between January 1995 and December 1999. Medical records and imaging studies were studied retrospectively. Patients’ clinical features and treatment modalities were analysed and major postoperative complications, including mortality, haematoma recurrence, infection and epileptic seizure, were studied. Results: All 108 patients underwent burr hole craniostomy for the drainage of CSDH; one patient also underwent formal craniotomy. Recurrence occurred in six (5.5%) patients, seizure in two (1.8%) and intracranial infection in one (0.9%). There were four deaths, giving rise to a mortality of 3.7%. All four patients who died were elderly and had presented in an unconscious state and died subsequently of chest infection after surgery. Conclusion: Although surgical drainage of CSDH is often considered to be a straightforward, effective and safe procedure, it is not entirely without risks. The surgical outcome of the present series is in accordance with the current standard of neurosurgical care.     

Chronic subdural haematoma in young and extremely aged adults: a comparative study of two age groups

To compare the clinical presentation, etiological factors and the outcome of chronic subdural haematoma (CSDH) in young and old adults, a retrospective analysis was performed by differentiating young adults, age<40 years (n=24) versus extremely aged adults, age>75 years (n=51). The clinical data, computed tomography (CT) findings and surgical outcome were recorded for analysis. We observed certain characteristics particular to young CSDH patients, higher incidence of headache (P<0.001) and vomiting (P=0.009), the shorter duration from trauma to operation (P=0.018) and more severe traumatic episodes (P=0.001). The older patients had a higher frequency of mental change (P=0.006), motor deficits (P=0.014) and larger haematomas (P<0.001). The surgical complication rate was not statistically different between the two age groups. An understanding of the varied clinical presentation of CSDH is essential to stimulate clinical suspicion and prompt evaluation, particularly for the differences between young and extremely aged patients.     

The Application of Transcranial Doppler Sonography in Patients with Chronic Subdural Haematoma

Summary  The aim of this study was to evaluate the haemodynamic changes of the middle cerebral artery (MCA) and their clinical significance before and after surgical aspiration in patients with chronic subdural haematoma (CSDH).  Nineteen patients with CSDH (17 unilateral and 2 bilateral) received transcranial Doppler sonography (TCD) examinations for cerebral blood flow velocity (CBFv) of the MCA prior to and 5 days after neurosurgical treatment. A total of 21 lesion and 10 non-lesion hemispheres were included. Cranial computerized tomography (CT) and clinical assessments were performed before and 3 months following surgery.  The preoperative TCD study revealed that the lesion hemisphere had a modest decrease in CBFv in the MCA as compared to the non-lesion hemisphere. Postoperatively, the CBFv significantly improved in the lesion hemisphere, but not in the non-lesion hemisphere, compared to the preoperative data (P<0.005). The improvement in CBFv showed no significant correlation with brain shift and haematoma volume of the initial cranial CT. Additionally, two patients, who were proved to have a postoperative complication of subdural pneumocephalus, failed to attend follow-up examinations of TCD.  Our results support TCD as an alternative follow-up examination for patients with CSDH, although it may not be sensitive enough as a preoperative screening tool. Postoperatively, improvements in the CBFv of the lesion hemisphere are characteristic. An unexplained difficulty of accessing cerebral basal arteries in follow-up TCD examinations should suggest pneumocephalus in the primary differential diagnosis.     

The risk factors for recurrence of chronic subdural hematoma

Chronic subdural hematoma (CSDH) is a common disease in the elderly, and the recurrence rate of CSDH is reported to range from 2.3 to 33 %. We performed a retrospective review of a number of CSDH cases and the potential factors associated with CSDH recurrence. The patient population comprised 112 men and 65 women with a mean age of 74.7 years. We analyzed the following factors: age, sex, antiplatelet and anticoagulant use, hematoma laterality, hematoma thickness, degree of midline shift and internal architecture of the hematoma in the preoperative CT films, use of irrigation, direction of the drainage tube, width of the subdural space, and degree of midline shift and the presence of a massive subdural air collection in the postoperative CT films. Univariate analysis revealed that there was a trend for different rates of recurrence among the different types of hematomas. The presence of a postoperative massive subdural air collection tended to be associated with the recurrence of hematoma. Multivariate analysis revealed that separated hematomas were significantly associated with CSDH recurrence, whereas the presence of postoperative massive subdural air collection tended to be associated with hematoma recurrence. Neither univariate nor multivariate analysis could demonstrate an association between the direction of the drainage tube and the recurrence of CSDH.     

Volume of chronic subdural haematoma: Is it one of the radiographic factors related to recurrence?

Background

Recurrence of chronic subdural haematoma (CSDH) is a significant issue in neurosurgical practice, and to distinguish individuals at high risk is important. In this study, we aim to clarify the relationship between quantitative haematoma volume and recurrence of CSDH.

Methods

For this two-year retrospective study, 94 patients with CSDH were enrolled and all underwent burr-hole craniostomy with closed-system drainage. The volume of haematoma before surgery was quantitatively analysed by computed tomography (CT) of the brain. The patients were subdivided into 2 groups based on whether recurrence of CSDH was present or not. We investigated the intergroup differences in the volume of haematoma and other radiographic parameters.

Results

Recurrence of CSDH was identified in 13 of 94 patients (14%). Univariable analysis of CT features revealed significant differences in the volume of haematoma, bilateral cerebral convexity, and layering of the haematoma. To adjust for the confounding effect, these 3 parameters were entered into multivariable logistic regression analysis. Ultimately, neither the volume of haematoma (p = 0.449) or bilateral cerebral convexity (p = 0.123) was relevant in this model. Only the presence of layering of the haematoma was independently associated with recurrence of CSDH (p = 0.009).

Conclusion

The volume of CSDH is not related to recurrence in patients undergoing burr-hole craniostomy with closed-system drainage. Layering of the haematoma was the only independent risk factor on CT images for recurrence of CSDH in our series.     

Very late onset of chronic subdural hematoma. Case report

A 56-year-old man developed subdural effusion after mild head trauma, which remained unchanged in volume and density on computed tomography during a follow-up period of 7 months. However, typical chronic subdural hematoma (CSDH) had developed by 9 months after the head trauma. The CSDH was successfully treated by irrigation and drainage. This unusually delayed onset of CSDH suggests that we should be aware of the possibility of very late onset of CSDH in patients with persistent asymptomatic subdural effusion.     

A case of complete clearance of chronic subdural hematoma accompanied by recurrent glioblastoma multiforme after administration of bevacizumab

The efficacy of bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), as an adjuvant therapy against various malignant tumors was recently established. Its pharmacological effects in malignant tumors, including gliomas, were speculated to involve neovascularization inhibition and vascular permeability. Recently, it has been reported that the outer membrane of chronic subdural hematoma (CSDH) contains high levels of VEGF, which were implicated in neovascularization of the outer membrane. Furthermore, studies suggested that VEGF has the etiology in CSDH development, although its involvement is not fully understood. Here, we report the first case of chronic subdural hematoma that was improved by bevacizumab administration for recurrent glioblastoma. The present case could contribute to the hypothesis that VEGF may be associated with CSDH. We also discuss the pathogenesis and mechanism of CSDH recurrence from the viewpoint of VEGF function.     

Treatment of chronic subdural hematoma by burr-hole craniostomy in adults: influence of some factors on postoperative recurrence

Summary Background. The study was conducted to determine the causative factors in the postoperative recurrence (PR) of chronic subdural haematomas (CSDHs) and to evaluate the efficacy of surgery in adults enrolled in this trial. Methods. 99 patients with 121 CSDHs, who were operated on between January 1999 and December 2001, were studied. We evaluated the PR rate related to anamnestic, clinical, surgical and neuroradiological imaging variables. In addition, we reviewed the number and the type of repeated operations, complications of surgery and the outcomes at one, three and 12 months. Findings. 82.6% of lesions were successfully treated following the initial evacuation, and 95.9% of lesions following a second procedure. The PR rate was 14.9%. A significantly high PR rate was found to be associated with separated type, frontal base type, a midline displacement >5 mm and the presence of acute subdural clots in cranial base type on CT scans obtained within four days postsurgery. The interval from head trauma to initial surgery <60 days, the maximum width of subdural space >10 mm and massive collection of air in the subdural space tended to give a high PR rate. The PR rate associated with the homogeneous type of CSDHs was significantly low. Age, sex, cause of CSDH, anticoagulant therapy, preoperative neurological presentation, concomitant disease, variables on preoperative CT scans, and surgical factors such as the extent of the surgical procedure, use of drainage, duration and volume of drainage were not significantly associated with PR rate. Conclusions. It is important to identify factors leading to a high or a low PR rate in the treatment of CSDHs because this may help to select appropriate surgical procedures and postoperative management to treat this condition efficiently.     

Intracerebral haemorrhage occurring at remote site following evacuation of chronic subdural haematoma

Summary We present a patient with an intracerebral haematoma occurring at a remote site following evacuation of a chronic subdural haematoma. Recurrence of the haematoma, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion are the major complications following operations for chronic subdural haematoma. An intracerebral haematoma following such evacuation is rare. Characteristically, haemorrhagic events on the ipsilateral side to the subdural haematoma is reported in the literature. According to our search, this is the first report of an intracerebral haematoma occurring at a remote site to the original lesion following evacuation of a chronic subdural haematoma. Correspondence: Cem Dinc, Icerenkoy Emniyet Cik. Sok. Aydin Kardesler Apt. No: 4/16, 34752 Kadıkoy, İstanbul, Turkey.     

A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma

Background

The usage of a drain following evacuation of a chronic subdural haematoma (CSDH) is known to reduce recurrence. In this study we aim to compare the clinical outcomes and recurrence rate of utilising two different types of drains (subperiosteal and subdural drain) following drainage of a CSDH.

Methods

Prospective randomised single-centre study analysing 50 patients who underwent CSDH treatment. Two types of drains, subperiosteal (SPD) and subdural (SDD), were utilised on consecutive alternate patients following burr-hole craniostomy, with a total of 25 patients in each group. The drains were left in for 48-h duration and then removed. The modified Rankin Scale (mRS) was used for outcome measurement at 3 and 6?months.

Results

Data analysis was performed by unpaired t test with Welch’s correction. It was observed that none of the patients in either group had haematoma recurrence during a 6-month follow-up, and a significant difference in outcome was noted at 6?months (p?=?0.0118) more than at 3?months (p?=?0.0493) according to the statistical analysis. Postoperative seizure and inadvertent placement of the subdural drain into the brain parenchyma were the two complications noted in this study. Anticoagulant use prior to the surgery did not affect the outcome in either group.

Conclusions

We conclude there was no recurrence of CSDH utilising the SDD and SPD following burr-hole craniostomy. The mRS measurement at the 6-month follow-up was found to be statistically significant, with better outcomes with utilisation of the SPD. The SPD may thus prove to be more beneficial than the SDD in the treatment of CSDH. A multi-centre study with a larger group of patients is recommended to reinforce the results from our study.     

Cerebrospinal fluid leakage into the subdural space: possible influence on the pathogenesis and recurrence frequency of chronic subdural hematoma and subdural hygroma

OBJECT: The purpose of this study was to clarify whether cerebrospinal fluid (CSF) leakage into the subdural space is involved in the genesis of chronic subdural hematoma (CSDH) and subdural hygroma (SH) and to clarify whether this leakage of CSF into the subdural space influences the postoperative recurrence rate of CSDH and SH. METHODS: In this prospective observational study, 75 cases involving patients treated surgically for CSDH (67 patients) or SH (8 patients) were evaluated with respect to clinical and radiological findings at presentation, the content of beta -trace protein (beta TP) in the subdural fluid (betaTPSF) and serum (betaTPSER), and the CSDH/SH recurrence rate. The betaTPSF was considered to indicate an admixture of CSF to the subdural fluid if betaTPSF/betaTPSER>2. RESULTS: The median beta TPSF level for the whole patient group was 4.29 mg/L (range 0.33-51 mg/L). Cerebrospinal fluid leakage, as indicated by betaTPSF/betaTPSER>2, was found to be present in 93% of the patients with CSDH and in 100% of the patients with SH (p=0.724). In patients who later had to undergo repeated surgery for recurrence of CSDH/SH, the betaTPSF concentrations (median 6.69 mg/L, range 0.59-51 mg/L) were significantly higher (p=0.04) than in patients not requiring reoperation (median 4.12 mg/L, range 0.33-26.8 mg/L). CONCLUSIONS: As indicated by the presence of betaTP in the subdural fluid, CSF leakage into the subdural space is present in the vast majority of patients with CSDH and SH. This leakage could be involved in the pathogenesis of CSDH and SH. Patients who experience recurrences of CSDH and SH have significantly higher concentrations of betaTPSF at initial presentation than patients not requiring reoperation for recurrence. These findings are presented in the literature for the first time and have to be confirmed and expanded upon by further studies.     

Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage

OBJECT: This study was conducted to determine the best position for the subdural drainage catheter to achieve a low recurrence rate after burr-hole irrigation and closed-system drainage of chronic subdural hematoma (CSDH). METHODS: The authors studied 63 patients with CSDH in whom the drainage catheter tip was randomly placed and precisely determined on postoperative computerized tomography (CT) scans and 104 patients with CSDH in whom CT scans were obtained 7 days postsurgery. The location of the subdural drainage catheter, the maximum postoperative width of the subdural space, and the percentage of the ipsilateral subdural space occupied by air postoperatively were determined and compared with the postoperative recurrence and reoperation rates. Patients with parietal or occipital drainage had a higher rate of CSDH recurrence and much more subdural air than those with frontal drainage. In addition, patients with residual subdural air demonstrated on CT scans obtained 7 days postsurgery also had a higher recurrence rate than those without subdural air collections. Furthermore, patients with a subdural space wider than 10 mm on CT scans obtained 7 days postsurgery had a higher recurrence rate than those with a space measuring 10 mm or less. CONCLUSIONS: The incidence of postoperative fluid reaccumulation seems to be reduced by placing the tip of the drainage catheter in the frontal convexity and by removing subdural air during or after surgery.     

Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study

Chronic subdural haematoma (CSDH) is a typical disease in elderly patients and encountered frequently in neurosurgical practice. With an increasing number of elderly people in the general population, there is a need to investigate risk factors (age, falls, anticoagulant or antithrombotic therapy) which could be pertinent to the development of this disease. We reviewed 354 patients undergoing surgery for CSDH over a period of 7 years (1996–2002), the occurrence being equally distributed over these years. CSDH occurred more often in elderly (65 years) than in younger people (69 vs 31%), and in men than in women (64 vs 36%). Falls were reported in 77% of patients. There was a trend towards a higher risk of falls in the elderly. Antithrombotic or anticoagulant therapy was present in 41% of patients, 32% of them having had falls. Overall postoperative mortality was 0% and overall recurrence rate 13.6%. CSDH in the elderly population, especially in men, is frequently associated with falls and anticoagulation or antithrombotic therapy. The indication for these medications, especially in elderly patients at risk for falls, should be carefully evaluated and controlled.These data were presented at the 8th EMN Congress, 21–24 May 2003 in Graz, Austria     

The importance of MRI findings for the diagnosis of nontraumatic lumbar subacute subdural haematomas

Summary Spinal subdural haematoma (SSH) is a rare cause of spinal cord or cauda equina compression which occurs mainly in patients with a bleeding diathesis. This report presents a case of subacute lumbar subdural haematoma demonstrated by magnetic resonance imaging. MRI appears to be more sensitive than myelography and CT.