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.     

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...     

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.     

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。     

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.     

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.     

改良式单孔锥颅置管引流术治疗慢性硬膜下血肿疗效分析

目的探讨改良式单孔锥颅置管引流术治疗慢性硬膜下血肿的临床疗效。方法选取2011-01—2013-01于我院就诊的慢性硬膜下血肿患者100例,按照入院编号随机分为观察组和对照组各50例。对照组给予常规穿刺治疗,观察组给予改良式单孔锥颅置管引流术治疗,观察2组临床效果。结果观察组痊愈30例(60.0%),好转20例(40.0%),总有效率100%;对照组痊愈26例(52.0%),好转18(36.0%),无效6例(12.0%),总有效率88.0%。观察组总有效率和痊愈率明显高于对照组(P0.05)。结论采用改良式单孔锥颅置管引流术治疗慢性硬膜下血肿症,能有效提高治疗效果,改善患者预后。     

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。     

双针穿刺治疗老年患者慢性硬膜下血肿

目的 总结30例经皮双针穿刺引流治疗老年患慢性硬膜下血肿效果，探讨慢性硬膜下血肿治疗方法。方法 本组30例慢性硬膜下血肿均经CT检查确诊，都行经皮双针穿刺引流术。结果 所有病例术后l～3d复查CT，血肿腔缩小90％以上，除10例有颅内积气外，未见颅内血肿、颅内感染、肺部感染和其它并发症。术后3～7d拔针，穿刺点一期愈合，痊愈出院，随访6-24月未见复发。结论 经皮双针穿刺引流治疗慢性硬膜下血肿是一种微创、简单、高效和并发症少的方法，但穿刺针需要作改进。     

单孔引流合并引流后鞘内灌注生理盐水治疗单房慢性硬膜下血肿体会

目的探讨单房慢性硬膜下血肿的治疗方法及效果。方法我院2001年1月至2010年1月共收治82例单房慢性硬膜下血肿患者,其中单侧72例,双侧10例,均采用单孔引流合并引流后鞘内灌注生理盐水治疗。结果 82例全部治愈,7例术后出现并发症,经处理后好转,无死亡病例。结论单房慢性硬膜下血肿采用单孔引流合并鞘内灌注生理盐水治疗,效果良好,并发症明显减少。     

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。