Contralateral acute epidural haematoma following evacuation of a chronic subdural haematoma with burr-hole craniostomy and continuous closed system drainage: a rare complication

Chronic subdural haematoma (CSDH) is one of the most frequent causes for neurosurgical intervention. Although the prognosis is generally good and treatment modalities are well established, some devastating intracranial haematomas can complicate its evacuation. The authors report here a case of an acute epidural haematoma occurring after evacuation of a contralateral chronic subdural haematoma (CSDH) with burr-hole craniostomy and continuous closed system drainage without irrigation. Since this is a rare, but potentially life-threatening, complication, clinicians should suspect its occurrence when an unexpected postoperative course is demonstrated.     

Chronic subdural haematoma associated with disturbance of consciousness: significance of acute-on-chronic subdural haematoma

Abstract

Objective:

Detailed features of chronic subdural haematoma (cSDH) associated with disturbance of consciousness and acute-on-chronic subdural haematoma (a/cSDH), in which acute subdural haematoma overlaps cSDH, remain poorly understood. The object of this study was to clarify both characteristics of cSDH associated with disturbance of consciousness and the significance of a/cSDH.

Methods:

Clinical factors and computed tomography (CT) findings were retrospectively investigated in 349 consecutive patients admitted between 2006 and 2013 and diagnosed with cSDH.

Results:

Glasgow Coma Scale (GCS) was ≤?8 in 21 patients (6.0%) and 9–14 in 29 patients excluding aphasia and/or dementia (8.3%). Multiple logistic regression analysis indicated that a/cSDH, female sex and haemodialysis were significantly related to severe disturbance of consciousness (GCS?≤?8). Predictors for a/cSDH observed in 29 patients (8.3%) were trauma history within 7?days before admission, high prothrombin time–international rate, and use of anticoagulants and/or antiplatelets. Unfavourable outcomes were observed in 29 of 299 patients (9.7%) without consciousness disturbance, compared to 27 of 50 patients (54%) with consciousness disturbance. Predictors of unfavourable outcome were consciousness disturbance, increase in age, malignancy, trauma history within 7?days and haemodialysis.

Discussion:

Disturbance of consciousness associated with cSDH, often caused by either a/cSDH or concomitant disease, frequently resulted in unfavourable outcomes. As a result, in cSDH patients associated with disturbance of consciousness, underlying conditions, especially a/cSDH, which is often caused by haemostatic abnormality, should be clarified and managed.     

Long-term survival after chronic subdural haematoma

Outcome after chronic subdural haematoma (CSDH) is invariably assumed favourable: however, little data regarding long term survival (LTS) exists. One study reported excess mortality restricted to year 1, but with expected actuarial rates thereafter. We aimed to determine LTS after CSDH in a retrospective analysis relative to actuarial data from age-matched controls. Data was obtained in n = 155, (M:F 97:58, 69.3 ± 2.3 years). Follow-up maxima was 14.19 years (mean: 4.02 ± 3.07 years, median: 5.2 years). Mortality in-hospital, at 6 months, 1 year, 2 years and 5 years was n = 13 (8.39%), n = 22 (14.19%), n = 31 (20.35%), n = 42 (27.1%) and n = 54 (34.84%). LTS was significantly worse than controls (5.29 ± 0.59 years vs. 17.74 ± 1.8 years, hazard ratio [HR]: 3.52, P < 0.0001). Death most frequently related to pneumonia/sepsis and ischemic heart disease (IHD). Median modified Rankin score (mRS) in those discharged home (n = 94, 60.65%) was 2 [IQR: 1–3]. Discharge mRS in those who died at 6 months, 1 year, 2 years and 5 years was 5 [IQR: 3–6], 5 [IQR: 4–6], 3 [IQR: 1–3], 4 [IQR: 2–5]. Discharge mRS was significantly worse with year 1 mortality (P = 0.014). LTS related to discharge mRS (HR: 37.006, P < 0.001), post-operative motor-score (HR: 0.581, P = 0.0026), IHD (HR: 5.186, P = 0.005), warfarin-use (HR: 5.93, P = 0.036) and dementia (HR: 5.39, P = 0.031). No long term recurrences (LTR) were recorded. Although most were discharged home with mRS = 2, LTS was markedly less than previously reported: peers lived 12.4 years longer. Although greater in year 1, excess mortality was not restricted to year 1, but continued throughout prolonged follow-up. LTS related to discharge disability and dependence, and co-morbid risk factors for cerebral atrophy. No LTR suggests that, once ultimately closed, the ‘subdural space’ remains closed. CSDH patients represent a vulnerable group who require continued long-term medical surveillance.     

Coagulopathy and outcome in patients with chronic subdural haematoma

OBJECTIVE: The coincidence of coagulatopathy and chronic subdural haematoma (CSH) requires correction of coagulation to facilitate surgery. We investigated the correlation between coagulopathy and outcome in CSH patients. MATERIAL AND METHODS: We analysed past medical history, surgical treatment and coagulation parameters of 114 patients. RESULTS: Coagulation disorders were found in 42%. Preoperative treatment with prothrombin complex concentrate was necessary in 14%. A significant difference (P < 0.05) of the preoperative level of platelets was found between recurrent CSH and non-recurrent group. Totally, we had to perform re-operations in 17.5%. Eighty-one patients presented with Glasgow coma scale (GCS) > or = 13. After surgery GCS was > or = 13 in n = 92. There was an improvement of GCS in 46 cases, 61 patients maintained GCS score levels. Outcome was significantly worse in the alcoholic group (P < 0.001), and in the recurrent group (P < 0.05). In patients with substitution of coagulation factors, outcome was worse in the group with post-operative substitution only (P < 0.05). CONCLUSION: In CSH, the coagulation parameters and a subtle correction of coagulation are of special interest, regarding the worse outcome in patients with recurrent CSH and in those requiring post-operative substitution.     

Burr-hole versus twist-drill drainage for theevacuation of chronic subdural haematoma:a comparison of clinical results

BACKGROUND: Most neurosurgeons remove clinically symptomatic subdural haematomata, but the techniques they choose remain controversial. METHOD: The results from sixty-two patients diagnosed with chronic subdural haematoma were evaluated for technique, postoperative computerized tomography (CT) scan results, and complications. RESULTS: Eleven patients had haematomata evacuated using twist-drill plus drain, 37 patients had haematomata evacuated with burr-hole only, and 14 patients were evacuated with burr-hole plus drain. Of the patients who underwent twist-drill and closed system drainage (CSD), 43% had smaller lesions on CT follow-up scans, as compared with 74% of those who underwent the burr-hole only procedure, and 65% with burr-holes with drains. Clinical outcome results showed that 64% of twist-drill and CSD patients deteriorated as compared with 16% of those with burr-hole only and 7% with burr-holes and CSDs. Sixty-four per cent of twist-drill patients required repeat evacuations as compared with 11% of those with burr-holes only, and 7% with burr-holes plus drains. CONCLUSION: The results at our institution indicate that burr-hole evacuation for chronic subdural haematoma is superior to twist-drill evacuation with respect to clinical outcomes and complications.     

Prospective randomized placebo-controlled double-blind clinical study of adjuvant dexamethasone with surgery for chronic subdural haematoma with post-operative subdural drainage: Interim analysis

Most chronic subdural haematomas (CSDH) are successfully treated neurosurgically. However, operative recurrences occur with a frequency 3–30%, consume resources and potentially prolong length-of stay (LOS). The only adjuvant factor proven to significantly decrease CSDH recurrence rate (RR) is post-operative subdural drainage. Corticosteroids have been used to conservatively manage CSDH. One non-randomised study also compared dexamethasone (DX) as an adjunct to surgery without post-operative drainage: whilst a null effect was observed, the ‘surgery-alone’ group consisted of only n = 13. We present an interim analysis of the first registered prospective randomised placebo-controlled trial (PRPCT) of adjuvant DX on RR and outcome after CSDH surgery with post-operative drainage. Participants were randomised to either placebo or a reducing DX regime over 2 weeks, with CSDH evacuation and post-operative drainage. Post-operative mortality (POMT) and RR were determined at 30 days and 6 months; modified Rankin Score (mRS) at discharge and 6 months. Post-operative morbidity (POMB) and adverse events (AEs) were determined at 30 days. Interim analysis at approximately 50% estimated sample size was performed (n = 47). Recurrences were not observed with DX: only with placebo (0/23 [0%] v 5/24 [20.83%], P = 0.049). There was no significant between-group differences in POMT, POMB, LOS, mRS or AEs.ConclusionsIn this first registered PRPCT, interim analysis suggested that adjuvant DX with post-operative drainage is both safe and may significantly decrease recurrences. A 12.5% point between-groups difference may be reasonable to power a final sample size of approximately n = 89. Future studies could consider adjuvant DX for longer than the arbitrarily-chosen 2 weeks.     

A retrospective analysis of chronic subdural haematoma recurrence rates following burr hole trephination versus minicraniotomy

The aim of this study was to determine the subdural haematoma recurrence rate in patients with symptomatic chronic subdural haematomas (CSDH) treated with either burr hole trephination (BHT) or minicraniotomy (MC) and to determine whether a statistically significant difference exists between the two techniques. A retrospective analysis of all consecutive patients with symptomatic CSDH treated with BHT or MC at the John Hunter Hospital Neurosurgery Department between July 2004 and July 2016 was performed. After inclusion/exclusion criteria were applied, 368 patients with 439 CSDHs were eligible. Baseline demographic data was recorded for all patients. Statistical analysis was performed assessing haematoma recurrence as the primary outcome and mortality as a secondary outcome. Three hundred and sixty eight patients were included in the study, with 225 being treated with MC and 143 with BHT. Baseline demographic data was similar between the two groups. The recurrence rate for patients treated with BHT was 0.13 (95% CI 0.08–0.18), versus 0.18 (95% CI 0.13–0.23) in the MC group. This difference was not statistically significant. Similarly, there was no statistically significant difference in mortality rates between the two groups. The mortality rate in the BHT group was 0.09 (95% CI 0.05–0.14) versus 0.09 (95% CI 0.05–0.13) in the MC group. In our series there was no difference in recurrence rates or mortality rates between the two groups, suggesting MC is an effective alternative to BHT in the management of symptomatic CSDH.     

微创钻孔密闭引流手术治疗慢性硬膜下血肿临床疗效观察

目的探讨观察微创钻孔密闭引流技术在慢性硬膜下血肿治疗中的应用价值。方法按入选标准及课题研究方案选取124例CSDH患者,随机分为A组(单孔钻孔引流)和B组(双孔钻孔密闭引流),分别统计分析两组手术、拔管、留院时间,气颅、血肿复发率、神经康复等指标。结果⑴与B组相比,A组的患者在手术时间、住院时间相比明显少(P0.01);⑵与B组相比,A组的患者气颅发生率较少(P0.05),两组在血肿复发率无统计学差异(P0.05)。⑶与B组相比,A组患者神经康复指标BI和GOS较低(P0.01)。结论⑴微创钻孔密闭引流术(单、双孔)是治疗CSDH的行之有效的方法,⑵单孔密闭引流术在手术及留院时间、气颅发生率方面具有优势,而在3个月神经康复方面双孔引流较好。     

单孔双管闭式引流治疗慢性硬膜下血肿

目的 探讨单孔双管闭式引流治疗慢性硬膜下血肿(CSDH)的临床治疗效果.方法 慢性硬膜下血肿患者随机按单孔单管额部引流组,单孔单管顶枕部引流组和单孔双管引流组,各选取30 例.分析其临床资料和影像学资料.结果 单孔双管引流组中线恢复好于其它二组(P ＜ 0.01),颅内积气和残留液体量三组比较均有显著差异(P ＜0.0...     

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。     

Occurrence and recurrence of spontaneous chronic subdural haematoma is associated with a factor XIII deficiency

Objective

In some patients, chronic subdural haematoma (cSDH) appears to occur spontaneously with frequent re-bleeding events. The pathophysiology of this phenomenon is still poorly understood. Because coagulation factor XIII (FXIII) is known to be involved in vascular integrity, endothelial barrier function and wound healing, we evaluated the role of FXIII in spontaneous cSDH.

Methods

We prospectively scrutinised the origin of cSDH in 117 patients and identified a subgroup of patients suffering from spontaneous cSDH who were included in this study. We analysed the plasma activity of FXIII and standard coagulation parameters and compared these data to age- and sex-matched healthy controls. We assessed the occurrence of re-bleeding events using clinical and imaging data and compared FXIII activity in patients with and without re-bleeding events.

Results

Out of 117 cSDH patients, 18 individuals suffered from spontaneous cSDH in this study. The patients with spontaneous cSDH showed significantly lower FXIII activity than the control group (65% [52.75, 80.25] (median [IQR]) vs. 93% [81, 111], P = 0.001), whereas standard coagulation parameters did not differ significantly between the groups. Six patients developed re-bleeding events after haematoma evacuation, and these patients expressed significantly lower FXIII activity compared to the other 12 patients (47.5% [33.5, 64] vs. 78.5% [58, 87], P = 0.005). The patient group with FXIII ≤ 68.5% differed significantly from the group with FXIII > 68.5% when categorised by the occurrence of re-bleeding events (n = 6/9 vs. n = 0/9, P = 0.009). This cut-off value predicted the re-bleeding events with a sensitivity of 100% and a specificity of 75% (positive predictive value: 66%, negative predictive value: 100%).

Conclusion

FXIII deficiency may play a pathophysiological role in spontaneous cSDH, so we suggest investigating FXIII activity because it may predict re-bleeding events after treatment. In individuals with considerably low FXIII activity, FXIII substitution may mitigate the chronic nature of this disease.     

Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience

BackgroundChronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH.MethodsRetrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010–2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination.ResultsThe overall survival in the cohort was 37.0 months (IQR: 20.0–60.0). The median age of the patients was 76 years (IQR: 66–82) and the median length of hospital stay was 10 days (range 1–126 days; IQR: 6–17 days). The recurrence rate was 6.37% (n = 17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04–3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41–4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26–3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically.ConclusionAge at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.     

钻孔闭式引流和YL-1型穿刺针引流治疗慢性硬膜下血肿的疗效观察

目的比较钻孔闭式引流和YL—1型穿刺针引流在治疗慢性硬膜下血肿(CSDH)的疗效。方法回顾分析了我院收治的62例CSDH病人,45例行钻孔闭式引流术(甲组),17例行YL—1型穿刺针引流术(乙组),比较两组治疗效果。结果甲组复发率为6.5％,并发症率为4.1％,乙组复发率为27.7％,并发症率为22.2％。结论钻孔闭式引流较YL-1型穿刺针引流可明显减少CSDH复发率和并发症发生率。     

一种新型封闭式钻孔引流术治疗慢性硬膜下血肿的临床疗效初步观察

目的观察慢性硬膜下血肿（CSDH）患者行单骨孔封闭冲洗及骨膜下引流术的疗效。 方法选取江阴市人民医院神经外科自2017年1月至2019年6月收治的CSDH患者106例,分为常规单骨孔钻孔引流术组（常规组）和单骨孔封闭冲洗及骨膜下引流术组（封闭组）,对2组患者的手术疗效及并发症进行统计分析。 结果2组患者的手术疗效比较差异无统计学意义（Z=0.262,P>0.05）;封闭组术后颅内积气量明显低于常规组,差异有统计学意义（Z=3.963,P<0.05）;2组患者术后症状性气颅、脑损伤、切口脑脊液漏、癫痫发作、血肿复发的发生率比较差异无统计学意义（P>0.05）。 结论单骨孔封闭冲洗及骨膜下引流术治疗CSDH能明显降低术后颅内积气,是一种简单、有效、安全的治疗手段。     

改良单孔引流治疗慢性硬膜下血肿67例体会

目的 探讨改良单孔引流术治疗慢性硬膜下血肿的可行性、实用性、有效性.方法 回顾性分析我科2004-03～2008-09 67例慢性硬膜下血肿采用改良单孔引流术治疗患者的临床资料.结果 67例患者经治疗后病情皆即明显改善,临床症状逐渐消失,随访1～1.5年,仅2例遗留少量硬膜下积液,无需特殊治疗,1年后自愈,其余病人预后良好,无复发.结论 采用改良单孔引流的手术方法 治疗慢性硬膜下血肿手术方法 简单,可降低传统单孔引流手术方式的诸多并发症,是一种有推广价值的手术方法.     

慢性硬膜下血肿钻孔引流术后复发的危险因素

目的 探讨慢性硬膜下血肿（CSDH）钻孔引流术后复发的危险因素。方法 回顾性分析2018年8月至2022年3月钻孔引流术治疗的188例CSDH的临床资料。术后6个月随访判断复发情况,采用多因素logistic回归模型分析术后复发的危险因素。结果 术后6个月,17例复发,复发率为9.04%;171例未复发。多因素logistic回归分析显示,血肿厚度>25 mm、双侧血肿、高密度血肿是CSDH钻孔引流术后复发的独立危险因素（P<0.05）。结论 CSDH钻孔引流术后具有一定的复发率。如果存在血肿厚度>25 mm、双侧血肿、高密度血肿等情况,CSDH病人钻孔引流术后复发的风险明显增高,应采取针对性措施预防复发,并密切随访。     

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.     

微创穿刺引流治疗慢性硬膜下血肿58例疗效分析

目的 观察微创穿刺抽吸、冲洗引流治疗慢性硬膜下血肿（CSDH）的疗效。方法 本组58例CSDH均经头颅CT和MRI检查确诊，采用YL-1型一次性使用颅内血肿粉碎穿刺针进行血肿微创穿刺抽吸、冲洗引流，血肿量50～120mL，引流时间3～5d。结果 58例中56例经一次穿刺抽吸、冲洗引流后治愈；2例引流无效，改行开颅血肿包膜切除术后治愈，无合并症，无死亡。结论 CSDH行微创穿刺抽吸、冲洗引流，创伤小、效果好、简便易行，可作为CSDH的有效治疗方法。     

A retrospective analysis of postoperative recurrence of septated chronic subdural haematoma: endoscopic surgery versus burr hole craniotomy

Objective: To identify the factors associated with Septated chronic subdural haematoma (sCSDH) recurrence and to compare the advantages and disadvantages of burr hole craniotomy (BHC) and endoscopic surgery (ES) with respect to preventing sCSDH recurrence.

Methods: A total of 76 consecutive patients with sCSDH underwent BHC or ES in our institution. Their clinical data were retrospectively analysed to identify the factors associated with sCSDH recurrence and to evaluate the effectiveness of BHC and ES with respect to preventing sCSDH recurrence.

Results: There were no significant differences in gender, age, Markwalder grade, side of haematoma, preoperative mid-line shifts, intervals, clinical features or medical histories between the two groups. Bilateral sCSDH was the only factor that significantly influenced the sCSDH recurrence rate (RR) (p = 0.001). Male gender, age ≥ 60 years, poor Markwalder grade, preoperative mid-line shifts ≤10 mm, postoperative mid-line shifts >10 mm, neovessels, intervals ≤20 days and medical histories tended to be associated with sCSDH recurrence. The RRs in the BHC and ES groups were 13.7 and 8.7%, respectively. ES eliminated more factors associated with recurrence than BHC; however, ES required more surgery time (p < 0.001) and more medical consumption (p < 0.001) than BHC.

Conclusions: Bilateral sCSDH exerted the most significant influence on the sCSDH RR. There was no difference between ES and BHC with respect to decreasing the sCSDH RR. However, BHC is a more efficient procedure than ES, as it required less surgery time and less medical consumption than ES.