Anticoagulants and antiplatelet agents and the risk of development and recurrence of chronic subdural haematomas

Seventy-one patients from northern Sweden were diagnosed with chronic subdural haematomas (CSDH) and treated at the Department of Neurosurgery at Umeå University Hospital over 12 months. Fifty-four patients with CSDH had a history of head trauma (trauma group), while 17 patients had no previous head trauma (non-trauma group). In the non-trauma group 71% of patients were treated with anticoagulants or antiplatelet aggregation agents (AAA) compared to 18% in the trauma group. Considering only AAA, 59% of the non-trauma patients were treated with these drugs versus 17% of patients in the trauma group. The recurrence rate for all patients was 17%. These findings confirm that the use of anticoagulants and AAA is over-represented in patients with non-traumatic CSDH. In our study, recurrence was not associated with previous use of anticoagulants or AAA.     

慢性硬膜下血肿患者D-二聚体检测的意义及氨甲苯酸术中冲洗血肿腔对其复发的影响

目的测定慢性硬膜下血肿(chronic subdural hematoma,CSDH)患者外周血和血肿液中D-二聚体的含量,探讨钻孔引流术中应用氨甲苯酸冲洗血肿腔对CSDH复发的影响。方法将49例CSDH患者随机分入试验组和对照组,测定外周静脉血和血肿液中D-二聚体的含量,试验组术中应用氨甲苯酸冲洗血肿腔,对照组应用生理盐水冲洗血肿腔,术后随访3个月,比较复发率。结果 (1)2组外周血和血肿液中D-二聚体含量差异无统计学意义(P0.05);(2)CSDH患者自身对照,血肿液中D-二聚体含量较外周血明显升高(P0.01)。(3)试验组术后复发率低于对照组(P0.05)。结论 CSDH患者血肿液中D-二聚体含量增高可能与其发病有关。氨甲苯酸可抑制纤溶亢进,术中冲洗血肿腔可降低CSDH的复发。     

Impact of time to resumption of antithrombotic therapy on outcomes after surgical evacuation of chronic subdural hematoma: A multicenter cohort study

BackgroundThe decision to resume antithrombotic therapy after surgical evacuation of chronic subdural hematoma (CSDH) requires judicious weighing of the risk of bleeding against that of thromboembolism. This study aimed to investigate the impact of time to resumption of antithrombotic therapy on outcomes of patients after CSDH drainage.MethodsData were obtained retrospectively from three tertiary hospitals in Singapore from 2010 to 2017. Outcome measures analyzed were CSDH recurrence and any thromboembolic events. Logistic and Cox regression tests were used to identify associations between time to resumption and outcomes.ResultsA total of 621 patients underwent 761 CSDH surgeries. Preoperative antithrombotic therapy was used in 139 patients. 110 (79.1%) were on antiplatelets and 35 (25.2%) were on anticoagulants, with six patients (4.3%) being on both antiplatelet and anticoagulant therapy. Antithrombotic therapy was resumed in 84 patients (60.4%) after the surgery. Median time to resumption was 71 days (IQR 29 – 201). Recurrence requiring reoperation occurred in 15 patients (10.8%), of which 12 had recurrence before and three after resumption. Median time to recurrence was 35 days (IQR 27 – 47, range 4 – 82 days). Recurrence rates were similar between patients that were restarted on antithrombotic therapy before and after 14, 21, 28, 42, 56, 70 and 84 days, respectively. Thromboembolic events occurred in 12 patients (8.6%), of which five had the event prior to restarting antithrombosis.ConclusionsTime to antithrombotic resumption did not significantly affect CSDH recurrence. Early resumption of antithrombotic therapy can be safe for patients with a high thromboembolic risk.     

慢性硬膜下血肿复发的影像学因素分析

目的通过影像学检查评估慢性硬膜下血肿（CSDH）复发的危险因素。 方法收集2014年1月至2018年12月在南通大学第二附属医院神经外科接受CSDH手术治疗的113例患者的临床资料。所有患者均接受钻孔外引流手术治疗,术后随访时间超过3个月,比较复发组与未复发组患者的临床资料,采用多因素Logistic回归分析CSDH患者复发的危险因素。 结果113例患者中,术后复发患者10例,未复发患者103例,术后复发率8.8%。复发组患者与非复发组患者在性别、年龄、术前血肿厚度、中线偏移比较差异均无统计学意义（P>0.05）,复发组与未复发组患者的血肿类型、血肿侧别比较,差异均具有统计学意义（P<0.05）。将单因素分析中有统计学意义的变量纳入Logistic回归分析,结果显示术前分隔分层和双侧血肿是CSDH复发的独立危险因素。 结论影像学术前血肿分隔分层型和双侧血肿是CSDH复发的危险因素。     

38例慢性硬脑膜下血肿钻孔引流术后复发分析

目的探讨影响慢性硬脑膜下血肿（Chronic subdural hematoma,CSDH）术后复发因素。方法回顾1995～2005年作者手术治疗38例CSDH患者,并结合有关文献资料进行相关分析。结果术后复发4例,复发率为10.02%,复发的患者平均年龄64岁。其中因术后颅内大量积气复发1例,高密度复发1例,等密度到混杂密度复发2例。结论患者的年龄、凝血机制异常、血肿的密度、术后积气和引流量的多少影响CDSH患者的预后。     

Chronic subdural hematoma preceded by traumatic subdural hygroma

Patients with traumatic subdural hygroma (SDG) are at an increased risk of developing chronic subdural hematoma (CSDH). However, the mechanism by which this occurs is still not fully understood. The purpose of this paper is to investigate the clinical characteristics and pathogenesis of CSDH, as well as the relationship between CSDH and SDG. We review the pertinent literature and retrospectively examine a series of cases in which CSDH had been preceded by SDG to understand the natural history and developmental mechanisms of these lesions. We discuss the cases of 24 patients in whom CSDH developed from traumatic SDG between 2001 and 2005. Headache was the most common symptom, and the mean Glasgow Coma Scale score was 14.1. Increases in SDG volume were observed in CT scans of 17 patients, and increased density and volume was observed in five patients. The mean interval between the two diseases was 57.6 days, and 13 patients developed new symptoms after the development of CSDH. The most common symptoms at that time were headache and hemiparesis. All patients underwent an operation, which resulted in good recovery in all but one case. The cycle of persistent SDG, rebleeding, coagulation and fibrinolysis contributes to the development of CSDH from SDG. It is important to understand the natural history of CSDH and carefully follow up patients with head injury, especially if it is associated with SDG, and the potential for the development of CSDH should be considered.     

蛛网膜囊肿合并慢性硬膜下血肿的治疗及临床分析

目的探讨蛛网膜囊肿合并慢性硬膜下血肿的临床特点及治疗方法。方法采用回顾性病例研究方法,对安徽省立医院神经外科2009年1月至2014年1月所收治的9例确诊为蛛网膜囊肿合并慢性硬膜下血肿患者进行分析,其中男6例,女3例,年龄1.5~60岁,平均23.9岁。临床表现为头痛患者8例;其中6例伴恶心、呕吐,1例伴有肢体无力,1例仅有肢体抽搐;有明确外伤史6例,无明确外伤史3例。结果9例患者中5例行颅骨钻孔硬膜下血肿引流术,5例患者术后均恢复良好,后出院;另2例行开颅硬膜下血肿清除并蛛网膜囊肿切除术,术后痊愈。2例患者行保守治疗,一月后复查头颅CT提示血肿较前缩小,患者无症状,未手术。9例患者分别随访10个月至4年,未再复发硬膜下血肿,生活质量可。结论蛛网膜囊肿合并慢性硬膜下血肿,常见于有头部外伤史的年轻患者。有明显临床症状者需手术治疗,并根据血肿量及是否合并囊内出血等,选择单纯做硬膜下血肿钻孔引流术还是同时开颅清除血肿并处理囊肿。     

Efficacy of endoscopic treatment for chronic subdural hematoma surgery

Endoscopic treatment is a potential therapeutic addition to chronic subdural hematoma (CSDH) surgery. However, the effect of endoscopic treatment remains controversial. Herein, we examined the optimal indication for endoscopic treatment in CSDH surgery. We retrospectively analyzed 380 consecutive patients with CSDH who underwent single burr-hole craniostomy. We defined postoperative rebleeding as radiological re-accumulation or increased computed tomography value of the hematoma. Reoperation was performed following further hematoma accumulation and/or neurological deterioration. Complicated CSDH was radiologically defined as a hematoma with a clot and/or fibrous septum. There were no differences in baseline characteristics or postoperative mortality and morbidity between the endoscope (97 patients) and control (283 patients) groups. The incidence of postoperative rebleeding (9.3% vs 25.1%, respectively; P = 0.001) and reoperation (0% vs 9.2%, respectively; P = 0.004) were significantly lower in the endoscope group versus controls. Multivariate analysis showed that males (odds ratio 2.14, 95% confidence interval 1.19–3.81; P = 0.012) and endoscopy (odds ratio 0.29, 95% confidence interval 0.13–0.59; P = 0.001) were independently associated with postoperative rebleeding. When CSDHs were divided into two types based on hematoma component, 175 patients exhibited complicated CSDH. There was a significant reduction in postoperative rebleeding (6.5% vs 23.0%, respectively; P = 0.010) and reoperation (0% vs 9.7%, respectively; P = 0.027) in complicated CSDH patients. Endoscopic treatment in CSDH surgery does not increase the risk of surgical complications. Complicated CSDH with a clot and/or septum may be an optimal indication for endoscopic treatment in CSDH surgery to reduce postoperative recurrence.     

Infantile acute subdural hematoma

A retrospective analysis of the infantile acute subdural hematoma was made with special reference to its pathogenesis. In 11 of 15 cases, the hematomas were bilateral or a contralateral subdural fluid collection was present. In 7 of 11 patients who underwent operation the collection was bloody fluid and/or clotted blood. In 3 patients, a subdural membrane, as seen in adult chronic subdural hematoma, was found. In only 1 patient with unilateral hematoma was clotted blood present without subdural membrane. The thickest collection of clotted blood was in the parasagittal region. It is postulated that in most cases hemorrhage occurs after minor head injury, from the bridging veins near the superior sagittal sinus, into a pre-existing subdural fluid collection such as chronic subdural hematoma or subdural effusion with craniocerebral disproportion, and that infants without intracranial disproportion are unlikely to have acute subdural hematoma caused by minor head injury.     

血府逐瘀汤辅助治疗慢性硬膜下血肿分析

目的 探讨中药血府逐瘀汤煎剂辅助治疗慢性硬膜下血肿术后颅内残余积气、积液的疗效.方法 收集术后3d颅内残余积气、积液量≥30ml的慢性硬膜下血肿病人61例,随机分为治疗组31例,接受血府逐瘀汤煎剂口服治疗,对照组30例,接受丹参注射液等静脉滴注治疗各2周,30d后CT随访并比较2组的残余积气、积液量.结果 治疗组中治愈29例,有效2例,无复发病例;对照组中治愈20例,有效4例,好转4例,复发2例. 结论 中药血府逐瘀汤煎剂辅助治疗慢性硬膜下血肿术后残余积气、积液与常规使用丹参注射液相比更有效,为防止其术后复发提供了一种安全、有效的治疗方法.     

血府逐瘀汤辅助治疗慢性硬膜下血肿分析

目的 探讨中药血府逐瘀汤煎剂辅助治疗慢性硬膜下血肿术后颅内残余积气、积液的疗效。方法 收集术后3d颅内残余积气、积液量≥30ml的慢性硬膜下血肿病人61例，随机分为治疗组31例，接受血府逐瘀汤煎剂口服治疗，对照组30例，接受丹参注射液等静脉滴注治疗各2周，30d后CT随访并比较2组的残余积气、积液量。结果 治疗组中治愈29例，有效2例，无复发病例；对照组中治愈20例，有效4例．好转4例，复发2例。结论 中药血府逐瘀汤煎剂辅助治疗慢性硬膜下血肿术后残余积气、积液与常规使用丹参注射液相比更有效，为防止其术后复发提供了一种安全、有效的治疗方法。     

Influence of antithrombotic agents on the recurrence of chronic subdural hematomas and the quest about the recommencement of antithrombotic agents: A meta-analysis

Antithrombotic agents (AT), including anticoagulants and antiplatelets, are risk factors of chronic subdural hematomas (CSDHs). However, the use of AT has not been clearly associated with postoperative recurrence (PR) in the literature before. Furthermore, the association between the resumption of AT and postoperative complications also requests research. Databases including Pubmed, Embase and Cochrane were searched for patients presenting with CSDH on anticoagulant or antiplatelet medication. Ten studies were included to analyze the association between the use of AT and PR: The meta-analysis showed that the use of AT, both anticoagulants (OR = 2.20, 95%CI [1.45, 3.33]; P = 0.0002) and antiplatelets (OR = 1.64, 95%CI [1.17, 2.30]; P = 0.004), could increase the PR rate. Two studies were included to analyze the relationship between the resumption of AT and postoperative complications. The meta-analysis showed that after the patients on AT resumed their medication, the risk of PR did not increase (OR = 0.33, 95%Cl [0.13, 0.80]; P = 0.01), and the occurrence of thromboembolism events had no statistical significance (OR = 1.30, 95%CI [0.26, 6.50]; P = 0.75). This meta-analysis demonstrated that AT were risk factors for the recurrence of CSDH. Recommencement of AT did not appear to increase the risk of postoperative hemorrhage, and could reduce the risk of thromboembolism. Thus, appropriate postoperative resumption of anticoagulants or antiplatelets may be safe. Still, more evidence is needed to answer the question about whether and how to resume AT.     

Idiopathic chronic subdural hematoma in the newborn: case report

Background Evidence of intrauterine development of chronic subdural hematoma (CSH) is extremely rare. A very limited number of cases with known and acceptable etiological explanation are reported. We were able to find out only four presented cases of intrauterine development of CSH without known etiology.Case report We present our case with a newborn baby with CSH without known etiology. Short literature review and possible etiological factors are observed.     

VEGF在慢性硬膜下血肿液及其外膜中的表达

目的探讨血肿液及其外膜血管内皮生长因子（VEGF）的表达与慢性硬膜下血肿（CSDH）发生发展的关系。方法利用酶联免疫吸附分析法（ELISA）对CSDH患者血肿液和血清中VEGF的含量进行测定，利用免疫组织化学方法观察CSDH血肿外膜的VEGF蛋白表达，并根据F．Ⅷ因子在血管内皮中的表达情况进行微血管密度（MVD）的计数，利用电镜观察血肿外膜的超微结构，分析在CSDH中VEGF对血肿外膜毛细血管的生成作用及血肿外膜中毛细血管的形态学改变。结果血肿液中VEGF的含量明显高于血清中的含量（P〈0．01），血肿外膜中可见明显增生的毛细血管和大量的炎症细胞，VEGF与F-Ⅷ因子均呈强阳性染色。电镜结果显示血肿外膜中存在大量新生毛细血管，血管通透性增高。结论VEGF与CSDH血肿外膜的毛细血管生成及血管通透性增高密切相关。     

37例慢性硬膜下血肿的临床诊疗体会

目的研究慢性硬膜下血肿的治疗及预后。方法对我院2009-10～2011-07 37例慢性硬膜下血肿行单孔钻孔引流术,对手术病人及病历进行回顾性分析。结果 37例病例中,36例痊愈出院。3例遗留少量硬膜下积液,5例颅内积气,均未特殊处理,门诊随访6～11个月后自愈。4例因血肿包膜机化严重,术后效果不佳二次开瓣手术,1例术后并发重症肺炎转入ICU后死亡。结论慢性硬膜下血肿虽然手术打击不重,但因病人年龄问题易出现并发症,应注意术前综合评估及术后护理。     

非外伤性与外伤性慢性硬膜下血肿的临床特征分析

目的 探讨外伤性和非外伤性慢性硬膜下血肿（CSDH）病人临床特征的差异。方法 回顾性分析2019年6月至2021年12月穿刺引流术治疗的47例CSDH的临床资料。结果 47例中,外伤性CSDH有31例（外伤组）,非外伤性16例（非外伤组）。外伤组年龄[（68.06±6.37）岁]明显低于非外伤组[（72.25±5.6）岁;P<0.05],高血压病史比例（29.03%）和抗凝/抗血小板药物使用比例（6.5%）明显低于非外伤组（分别为68.75%、56.3%;P<0.05）,术后3个月Markwalder’s分级不良率（6.45%）明显低于非外伤组（31.25%;P<0.05）。结论 非外伤性CSDH病人年龄偏大,抗血小板/抗凝药物使用更为常见,血压偏高,血肿吸收较慢,术后3个月预后较差,值得临床关注。     

慢性硬膜下血肿脂联素和基底膜蛋白多糖的表达

目的 探讨慢性硬膜下血肿脂联素(APN)、基底膜蛋白多糖(PL)的表达变化.方法 2019年5月至2020年5月钻孔引流术治疗CSDH共32例,所有病人入院后均服用阿托伐他汀钙片,直至复查CT示血肿完全吸收.术前、术后3 d、术后3周各取静脉血5 ml,术中采集血肿液5 ml,采用酶联免疫吸附法检测APN和PL的浓度....     

慢性硬膜下血肿钻孔引流术后硬膜下脓肿形成的治疗

目的慢性硬膜下血肿术后并发硬膜下脓肿极为罕见,治疗方式多为再次置管引流,而选择开颅治疗极少,本文将对其开颅治疗进行讨论。方法回顾报道开颅手术治疗的两例慢性硬膜下血肿钻孔引流术后并发硬膜下脓肿的病例。结果两例病人预后均较好,未残留明显的神经系统受损体征。结论硬膜下脓肿术前的影像学评估十分重要,手术方式是选择再次钻孔引流还是开颅手术需依据术前影像学特征来合理选择,静脉应用敏感抗生素一定要足量、全程。     

慢性硬膜下血肿外膜的超微结构观察

目的 通过对慢性硬膜下血肿(CSDH)外膜的超微结构观测,探讨CSDH发生和发展的病理学基础. 方法 收集天津医科大学总医院神经外科自2008年1月至2009年1月间行血肿清除术的8例CSDH患者的外膜标本,其中CT显示血肿密度为低密度2例,等密度2例,高密度2例,混杂密度2例.应用光镜和电镜观察血肿外膜上新生血管的形态和结构. 结果 光镜下可见血肿外膜大量新生的毛细血管扩张充血,并可见含铁血黄素沉积.电镜下可见血肿外膜组织含大量成纤维细胞和毛细血管;部分毛细血管内皮细胞结构异常,可见损伤内皮细胞,不连续,毛细血管周围常有红细胞渗出;部分毛细血管结构完整,扩张不明显,血管中有微血栓形成、组织中嗜酸性粒细胞增多,颗粒大,部分与成纤维细胞接触,有时可见中性粒细胞和巨噬细胞,成纤维细胞活化明显,呈增殖状态.毛细血管内皮细胞的结构异常和红细胞渗出在血肿密度为高密度者的标本中最为明显. 结论 CSDH外膜新生血管的形成及反复再出血是CSDH发生和发展过程中的关键因素.     

双侧慢性硬膜下血肿的微创治疗

目的 探讨双侧慢性硬膜下血肿的诊治方法及效果.方法 回顾性分析2001-04～2006-05收治的28例双侧慢性硬膜下血肿的临床资料,首诊即行颅脑CT检查22例（79%）,MRI检查16例（57%）.首诊误诊3例,漏诊1例.28例术前诊断均正确.治疗方法均采取局麻下行双侧钻单孔冲洗引流术.结果 27例术后均痊愈,1例出现硬膜下积液,全组无死亡病例.结论 双侧慢性硬膜下血肿确诊的首选方法是颅脑CT,必要时辅以MRI检查;双侧钻单孔微创术为首选治疗方法,效果良好.