Volume and Midline Shift as Preoperative Computed Tomography Imaging Predictors of Postoperative Chronic Subdural Hematoma Recurrence: Retrospective Review of 345 Patients With 412 Operative Subdural Sides

Abstract INTRODUCTION The treatment and management of chronic subdural hematoma (cSDH) is highly variable, with recurrent surgery resulting in increased elderly morbidity, and economic burden to patients and the healthcare system. By conducting a retrospective review of patients with cSDH who underwent evacuation, we will provide a better understanding of predictive factors of recurrence, thereby optimizing a surgeon's management and treatment. METHODS We conducted a retrospective review of 345 patients with a total of 412 sides of cSDH, who received either burr-hole craniostomy or a craniotomy with closed system drainage. We reviewed the immediate preoperative and postoperative computed tomography (CT) scan, and defined recurrence as repeat surgical intervention on the side of initial evacuation. We performed a per-patient and per-side analysis of the collected data. RESULTS A total of 49 (11.9%) patients and 51 sides (12.4%) experienced a recurrent cSDH requiring re-evacuation. In the per-patient analysis, the preoperative hematoma volume [CI 1.082 (1.013-1.155)] and midline shift at the third ventricle [CI 1.118 (1.1028-1.215)] were predictors of recurrence. This was also observed in the per-side analysis at CI 1.088 (1.021-1.159) and CI 1.130 (1.045-1.222), respectively. On the per-patient side, comorbidities (diabetes, liver disease, alcohol abuse, antiplatelet/anticoagulant medication) and other demographic factors (gender, age) were not linked to recurrence. If a patient had a bilateral hematoma and both sides were operated on, it was found to be protective of recurrence with a CI of 0.111 (0.025-0.486). CONCLUSION Larger preoperative volumes and a greater midline shift significantly increased the risk of re-evacuation for cSDH, while other demographic and CT characteristics did not. Therefore, this may represent that a high-risk subgroup can be used as a target for preventative therapy.

Download Full-text

Kernohan-Woltman notch phenomenon and intention tremors in case of chronic subdural hematoma

Romanian Neurosurgery ◽

10.2478/romneu-2014-0013 ◽

2014 ◽

Vol 21 (1) ◽

pp. 109-112

Author(s):

P. Sasikala ◽

Bindu Menon ◽

Amit Agarwal

Keyword(s):

Ct Scan ◽

Movement Disorders ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Mass Effect ◽

Midline Shift ◽

Rare Presentation ◽

Surgical Evacuation ◽

Significant Mass Effect ◽

Significant Mass

Abstract Movement disorders are atypical and rare presentation of chronic subdural hematomas. We report a case of 60 year man who presented with intention tremors and altered sensorium. The patient had Kernohan-Woltman notch phenomenon on clinical examination. CT scan brain showed a large left fronto-temporo-parietal chronic subdural hematoma with significant mass effect and midline shift. His symptoms relieved completely after surgical evacuation of the hematoma.

Download Full-text

Etizolam, an Anti-anxiety Agent, Attenuates Recurrence of Chronic Subdural Hematoma. Evaluation by Computed Tomography.

Neurologia medico-chirurgica ◽

10.2176/nmc.42.53 ◽

2002 ◽

Vol 42 (2) ◽

pp. 53-56 ◽

Cited By ~ 10

Author(s):

Yutaka HIRASHIMA ◽

Naoya KUWAYAMA ◽

Hideo HAMADA ◽

Nakamasa HAYASHI ◽

Shunro ENDO

Keyword(s):

Computed Tomography ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma

Download Full-text

Chronic subdural hematoma - diagnosis, treatment and perspectives

Medicinski pregled ◽

10.2298/mpns2010295j ◽

2020 ◽

Vol 73 (9-10) ◽

pp. 295-300

Author(s):

Mirela Jukovic ◽

Viktor Till

Keyword(s):

Computed Tomography ◽

Subdural Hematoma ◽

Diagnostic Method ◽

Clinical Presentation ◽

Management Strategies ◽

Disease Onset ◽

Chronic Subdural Hematoma ◽

Disease Therapy ◽

Conservative And Surgical Treatment

Introduction. Chronic subdural hematoma has become an important entity in radiological, neurological and neurosurgery practice. Classification. The classification of chronic subdural hematoma is most often done in relation to the time of the disease onset (acute, subacute and chronic), whereas the second classification is based on hematoma density using computed tomography. Clinical presentation. The clinical presentation may mimic a spectrum of various diseases and chronic subdural hematoma can be easily overlooked without radiological verification. Diagnosis. The diagnosis of chronic subdural hematoma is partly clinical and partly radiological. In most cases, computed tomography is the initial diagnostic method for detection of this disease. Many studies point to different management strategies in the diagnosis and treatment of the disease. Therapy. The therapy of chronic subdural hematoma depends on the patient?s neurological deficit, but generally it is divided into conservative and surgical treatment. Conclusion. The aim of this paper is to review chronic subdural hematomas with reference to their clinical and radiological characteristics for better understanding of these phenomena.

Download Full-text

Spontaneous resolution of large non-traumatic bilateral acute-on-chronic subdural hematoma

Romanian Neurosurgery ◽

10.1515/romneu-2017-0002 ◽

2017 ◽

Vol 31 (1) ◽

pp. 8-16

Author(s):

D. Adam ◽

D. Iftimie ◽

Gina Burduşa ◽

Cristiana Moisescu

Keyword(s):

Conservative Treatment ◽

Subdural Hematoma ◽

Clinical Presentation ◽

Surgical Intervention ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Neurological Status ◽

Spontaneous Resolution ◽

Subdural Hematomas ◽

Gcs Score

Abstract Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases. Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis. Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Download Full-text

Trephine Craniotomy versus Burr Hole Drainage for Chronic Subdural Hematoma—An Institutional Analysis of 156 Patients

Indian Journal of Neurotrauma ◽

10.1055/s-0040-1713461 ◽

2020 ◽

Vol 17 (02) ◽

pp. 110-120

Author(s):

Ramesh Chandra Vemula ◽

B. C.M. Prasad ◽

Venkat Koyalmantham ◽

Kunal Kumar

Keyword(s):

Ct Scan ◽

Recurrence Rate ◽

Subdural Hematoma ◽

Surgical Intervention ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

P Value ◽

First Choice ◽

Significant Difference ◽

Preoperative Ct

Abstract Introduction Some neurosurgeons believe that doing a trephine craniotomy (TC) decreases the chance of recurrence in chronic subdural hematoma (cSDH). But this is not supported by any evidence. Methods A retrospective analysis of patients who were operated for cSDH from 2014 to 2019 at our institute was done. Factors causing recurrence were studied. Results A total of 156 patients were operated in the given period, among which 88 underwent TC and 68 patients underwent burr hole drainage (BHD) for evacuation of cSDH. All patients underwent two trephines or two burr holes placed according to the maximum thickness of the hematoma. Rate of recurrence in trephine group was 12.5% and in burr-hole group was 11.76% and was not statistically significant. Significant factors for recurrence included nontraumatic cSDH, anticoagulant use, presence of membranes, preoperative computed tomography (CT) showing iso- or mixed-density subdural collection and SDH volume > 60 mL. There was selection bias for the procedure. Patients with subdural membranes were preferentially taken for TC as the percentage of subdural membrane found intraoperatively was significantly greater in trephine group (51.1%) than burr-hole group (17.6%) (p value < 0.001).When all the patients who showed membranes in CT scan were excluded, there was no statistical difference in the base line characteristics of both the groups. After excluding the patients with membranes in preoperative CT scan, there was no significant difference in recurrence rate between the two groups.In TC group with membranes, 8 out of 45 had recurrence, whereas in burr-hole group with membranes, 8 out of 12 had recurrence. This difference was statistically significant. (p value < 0.001). Conclusion Surgical intervention in both modalities improves patient outcome with an overall recurrence rate of 12.17%. In the absence of any identifiable membranes in preoperative CT scan, BHD is the preferred surgical intervention. We prefer TC as first choice for patients with membranes in CT scan.

Download Full-text

Comparative Study of Surgical Outcome of Chronic Subdural Hematoma Treated with and without External Drainage

Eastern Green Neurosurgery ◽

10.3126/egn.v2i1.27459 ◽

2020 ◽

Vol 2 (1) ◽

pp. 30-34

Author(s):

Suresh Sapkota ◽

Kiran Niraula ◽

Subash Lohani ◽

Shikher Shrestha ◽

Bibhusan Shrestha ◽

...

Keyword(s):

Local Anesthesia ◽

Subdural Hematoma ◽

Surgical Outcome ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Midline Shift ◽

External Drainage ◽

Presenting Symptoms ◽

Number Of Patients ◽

Significant Difference

Background and purpose: Chronic subdural hematoma (cSDH) poses a significant morbidity and mortality risk particularly in elderly population. It can be treated with simple surgical techniques like burr hole drainage under local anesthesia, however it often recurs after surgical evacuation in significant number of patients. Material and methods: A randomized controlled trial was designed at Mayo Hospital/KEMU in 2013 to 2016. Total number of 98 patients who met the inclusion and exclusion criteria were randomized into ‘with drain’ and ‘without drain’ arm. All of them were treated with burr hole drainage under local anesthesia. Half of them had subdural drain while the remaining half did not. Recurrence of hematoma and surgical outcome was compared. Result: Among 98 patients included in the study(54 males and 44 females) met the inclusion criteria. Mean age of presentation was 63 years ± 12.4 (range 40-100). There was left sided preponderance in hematoma location (53.1%). Mean midline shift was 2.7 mm ± 1.5. Owing to drainage of cSDH, post-operative MRC score of patients along with midline shift in the CT brain showed statistically significant improvement. However, irrespective of insertion of drainage system, there was no significant difference noted in recurrence of cSDH, midline shift and improvement in presenting symptoms (hemiparesis or monoparesis) considering all post-operative days. Conclusion: There is no significant difference in recurrence rate depending on weather a postoperative external drainage is placed or not.

Download Full-text

Bilateral Chronic Subdural Hematoma in the Posterior Fossa Treated with a Burr Hole Irrigation: A Case Report and Review of the Literature

Case Reports in Neurology ◽

10.1159/000498856 ◽

2019 ◽

Vol 11 (1) ◽

pp. 87-93

Author(s):

Takuro Inoue ◽

Hisao Hirai ◽

Ayako Shima ◽

Fumio Suzuki ◽

Masayuki Matsuda

Keyword(s):

Computed Tomography ◽

Case Report ◽

Posterior Fossa ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Ventricular Drainage ◽

Review Of The Literature ◽

Bilateral Chronic Subdural Hematoma ◽

Radiological Examinations

Chronic subdural hematoma (CSH) in the posterior fossa is extremely rare. The surgical strategy is still controversial. We report a case of bilateral CSH in the posterior fossa successfully treated with a single-burr hole surgery. A 74-year-old man under anticoagulation and antiplatelet therapy developed headache and nausea during observation for an asymptomatic supratentorial CSH. Radiological examinations revealed appearance of bilateral CSH in the posterior fossa associated with hydrocephalus. Upon rapid deterioration of the patient’s consciousness, an urgent treatment was required. A burr hole was made near the transverse-sigmoid junction on the left side to access the hematoma. No ventricular drainage was placed as his consciousness improved during the decompression of the hematoma. Postoperative computed tomography showed that bilateral CSH and hydrocephalus had been successfully treated. In bilateral CSH in the posterior fossa, there may be a connection between each side. CSH in the posterior fossa, when urgent, can be treated under local anesthesia with a unilateral burr hole irrigation.

Download Full-text

Frequency of and Risk Factors for Chronification in Traumatic Acute Subdural Hematoma following Conservative Therapy

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1685188 ◽

2019 ◽

Vol 80 (05) ◽

pp. 359-364 ◽

Cited By ~ 2

Author(s):

Stefanie Kaestner ◽

Marina van den Boom ◽

Wolfgang Deinsberger

Keyword(s):

Risk Factors ◽

Subdural Hematoma ◽

Head Injuries ◽

Chronic Subdural Hematoma ◽

Length Of Hospital Stay ◽

The Elderly ◽

Coagulation System ◽

Acute Subdural Hematoma ◽

Neurosurgical Department ◽

Anticoagulant Medication

Background In an aging society, traumatic head injuries, such as acute subdural hematomas (aSDHs), are increasingly common because the elderly are prone to falls and are often undergoing anticoagulation treatment. Especially in advanced age, cranial surgery such as craniotomies may put patients in further jeopardy. But if treatment is conservative, a chronic subdural hematoma (cSDH) may develop, requiring surgical evacuation. Existing studies have reported a correlation between several risk factors contributing to the frequency of chronification. To improve the prediction of the course of disease and to aid counseling patients and relatives, this study aimed to determine the frequency and the main risk factors influencing the process of chronification of an aSDH following conservative treatment. Methods We identified patients presenting between January 2012 and September 2017 at our neurosurgical department with an aSDH. All patients treated conservatively were selected retrospectively, and the following parameters were documented: age, sex, chronification status, Glasgow Coma Scale score on admission and discharge, hematoma thickness and density, the degree of midline shift (MLS), prior anticoagulants and administration of procoagulants, thrombosis management, other coagulopathies, initial length of hospital stay, interval between discharge and readmission, and interval between initial injury and date of surgery and last follow-up. The cohort was divided into patients with complete resolution of their aSDH, and patients who needed surgery due to chronification. Results A total of 75 conservatively treated patients with aSDH were included. A chronification was observed in 24 cases (32%). The process of chronification takes an average of 18 days (range: 10–98 days). The following factors were significantly associated with the process of chronification: age (p = 0.001), anticoagulant medication (acetylsalicylic acid [ASA], Coumadin, and novel anticoagulants [NOACs]) before injury (p = 0.026), administration of procoagulants (p = 0.001), presence of other coagulopathies such as thrombocytopenia (p = 0.002), low hematoma density at discharge (p = 0.001), hematoma thickness on admission and discharge (p = 0.001), and the degree of MLS (p = 0.044). Conclusion Chronification occurred in a third of all patients with conservatively treated aSDH, on average within 3 weeks. The probability of developing a cSDH is 0.96 times higher with every yearly increase in age, resulting in 56% chronification in patients ≥ 70 years. Hematoma thickness and impairment of the coagulation system such as anticoagulant medication (ASA, Coumadin, and NOACs) or thrombocytopenia are further risk factors for chronification.

Download Full-text

Anticoagulant and antiplatelet use in seniors with chronic subdural hematoma

Neurology ◽

10.1212/wnl.0000000000003918 ◽

2017 ◽

Vol 88 (20) ◽

pp. 1889-1893 ◽

Cited By ~ 34

Author(s):

Santhosh Nathan ◽

Zahra Goodarzi ◽

Nathalie Jette ◽

Clare Gallagher ◽

Jayna Holroyd-Leduc

Keyword(s):

Older Adults ◽

Subdural Hematoma ◽

Odds Ratio ◽

Antiplatelet Agent ◽

Chronic Subdural Hematoma ◽

Antiplatelet Agents ◽

Antiplatelet Medication ◽

Increased Risk ◽

Anticoagulant Medication ◽

Combined Data

Objective:To address whether to restart older patients on anticoagulants or antiplatelet agents in the setting of a chronic subdural hematoma (cSDH).Methods:This is an update of a previous review (searched until July 2012). Medline, EMBASE, ISI Web of Knowledge, Google Scholar, PLOS, and the Cochrane Register for Systematic Reviews databases were searched from January 2012 to December 2016. Studies included older adults (those over 65 years) experiencing traumatic subdural hematoma or cSDH who were on anticoagulation or antiplatelet agents.Results:Seven studies were included (mean age 72 years). Four out of 7 studies provided combined data on anticoagulants or antiplatelet use. Only one study found anticoagulant or antiplatelet agent use to be a significant factor for cSDH rebleeding. Two studies considered anticoagulant use only and both reported similar increased odds of rebleeding (odds ratio [OR] 1.75, 95% confidence interval [CI] 0.18–16.86; OR 2.7 95% CI 1.42–6.96). Antiplatelets were not found to be associated with rebleeding. Ideal timing to resume anticoagulants or antiplatelets was unclear.Conclusions:Anticoagulant medication was associated with increased rebleeding risk in older adults with cSDH. However, antiplatelet medication was not associated with increased risk of rebleeding.

Download Full-text

Factors Predicting the Need for Surgery of the Opposite Side After Unilateral Evacuation of Bilateral Chronic Subdural Hematomas

Neurosurgery ◽

10.1093/neuros/nyy432 ◽

2018 ◽

Vol 85 (5) ◽

pp. 648-655 ◽

Cited By ~ 3

Author(s):

Rouzbeh Motiei-Langroudi ◽

Ajith J Thomas ◽

Luis Ascanio ◽

Abdulrahman Alturki ◽

Efstathios Papavassiliou ◽

...

Keyword(s):

Computed Tomography ◽

Chronic Subdural Hematoma ◽

Reoperation Rate ◽

Contralateral Side ◽

Significant Determinant ◽

Midline Shift ◽

Significant Difference ◽

Hematoma Growth ◽

Bilateral Chronic Subdural Hematoma ◽

Symptomatic Side

Abstract BACKGROUND Patients with bilateral chronic subdural hematoma (bCSDH) undergo unilateral evacuation for the large or symptomatic side because the contralateral hematoma is either small or asymptomatic. However, the contralateral hematoma may subsequently grow and require evacuation. OBJECTIVE To characterize factors that predict contralateral hematoma growth and need for evacuation. METHODS A retrospective study on 128 surgically treated bCSDHs. RESULTS Fifty-one and 77 were bilaterally and unilaterally evacuated, respectively. Glasgow Coma Scale was lower and midline shift was higher in those evacuated unilaterally compared to those evacuated bilaterally. Hematoma size was a significant determinant of decision for unilateral vs bilateral evacuation. The contralateral side needed evacuation at a later stage in 7 cases (9.1%). There was no significant difference in terms of reoperation rate between those evacuated unilaterally and bilaterally. Greater contralateral hematoma thickness on the first postoperative day computed tomography (CT) and more postoperative midline shift reversal had higher rates of operation in the opposite side. There was no difference between the daily pace of hematoma decrease in the operated and nonoperated sides (0.7% decrease per day vs 0.9% for the operated and nonoperated sides, respectively). CONCLUSION Results of this study show that most bCSDHs evacuated unilaterally do not experience growth in the nonoperated side and unilateral evacuation results in hematoma resolution for both sides in most cases. Hematoma thickness on the opposite side on the first postoperative day CT and amount of midline shift reversal after surgery are the most important factors predicting the need for surgery on the opposite side.

Download Full-text