Endoscopic evacuation of septated chronic subdural hemorrhage – Technical considerations, results, and outcome

Background: Chronic subdural hematoma (cSDH) is a common entity in the elderly. Homogeneous or well-liquefied CSDH has a standard line of treatment through burr hole and irrigation. However, the management of septated chronic subdural hematoma (sCSDH) with multiple membranes does not have a well-defined surgical approach. The neomembranes forming septations prevent evacuation of clots through burr holes, and the small remaining loculi with clots will enlarge overtime to cause recurrence. Methods: Patients with sCSDH were operated through a minicraniotomy (2.5 cm × 2.5 cm) using rigid endoscopes for visualization of the subdural space. Using endoscope, the entire subdural space can be visualized. The neomembranes are removed with standard neurosurgical microinstruments. The entire cavity is irrigated under vision to remove all clots and ensures hemostasis. Results: Eighty-three endoscope-assisted evacuations were done in 68 patients from January 2016 to April 2020. Fifty (73.5%) patients had unilateral and 18 (26.5%) had bilateral subdural. Only 1 patient (1.47%) had a clinically significant recollection of subdural bleeding 1 month after the procedure. Over a mean follow-up period of 25.3 months (range 1–53 months), rest of patients did not show any recollection. Conclusion: Endoscopic evacuation of sCSDH is a safe and effective method and can be used to improve clot evacuation, and remove neomembranes under direct vision to reduce the rates of recollection. This method also obviates the need for larger craniotomies to remove membranes.

Download Full-text

Single versus Double Burr Holes for Treating Chronic Subdural Hematoma

Bangladesh Journal of Neurosurgery ◽

10.3329/bjns.v9i2.44882 ◽

2020 ◽

Vol 9 (2) ◽

pp. 99-104

Author(s):

Uzzal Kumer Sadhu Khan ◽

Asit Chandra Sarker ◽

Md Mahamudul Haq Morshed ◽

Md Motasimul Hasan ◽

Saiful Hoque ◽

...

Keyword(s):

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Cerebral Atrophy ◽

The Elderly ◽

Burr Hole ◽

Group A ◽

Group B ◽

Burr Holes ◽

Better Than

A subdural hematoma is a collection of blood below the inner layer of the dura but external to the bran and arachnoid membrane.Chronic subdural hematoma is commonly associated with cerebral atrophy, occur in the elderly after apparently insignificant head trauma. The incidence of Chronic subdural hematoma increases with age and after 70 years of age. Surgical evacuation of hematoma is indicated in patients who are clinically deteriorate or do not improve. Surgery can bring a rapid clinical improvement with a favorable outcome in over 80% of patient. Methods: This study was a prospective intervention study. Results: It was observed that 29 (96.6%) patients were alive in group A and 27 (90.0%) patients alive in group B in GOS scoring on the 7th POD. The alive patients were again divided into 4 sub groups, as shown in the table. Among total 60 patients, in Group A 1(3.4%) died and 3 (10.0%) died in Group B. After 3 months follow up, it was observed that 29 (96.6%) patients were alive in group A and 27 (90.0%) patients alive in group B. The alive patients were again divided into 4 sub groups, as shown in the table. Persistent vegetative and severe disability was not improved in Group B. Conclusion: In my study it was observed that the surgical outcome in single burr hole craniotomy is better than double burr hole craniotomy for treating of chronic subdural hematoma. Bang. J Neurosurgery 2020; 9(2): 99-104

Download Full-text

Chronic subdural hematoma in the elderly: not a benign disease

Journal of Neurosurgery ◽

10.3171/2010.8.jns10298 ◽

2011 ◽

Vol 114 (1) ◽

pp. 72-76 ◽

Cited By ~ 154

Author(s):

Lucas Bernardes Miranda ◽

Ernest Braxton ◽

Joseph Hobbs ◽

Matthew R. Quigley

Keyword(s):

Mortality Rate ◽

Median Survival ◽

Subdural Hematoma ◽

Excess Mortality ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Benign Disease ◽

Twist Drill ◽

Chi Square Analysis

Object Chronic subdural hematoma (CSDH) is perceived to be a “benign,” easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization. Methods The authors conducted a retrospective review of data obtained in a prospectively identified consecutive series of adult patients admitted to their institution between September 2000 and February 2008 and in whom there was a CT diagnosis of CSDH. Survival data were compared to life-table data. Results Of the 209 cases analyzed, 63% were men and the mean age was 80.6 years (range 65–96 years). Primary surgical interventions performed were bur holes in 21 patients, twist-drill closed-system drainage in 44, and craniotomies in 72. An additional 72 patients were simply observed. Reoperations were recorded in 5 patients—4 who had previously undergone twist-drill drainage and 1 who had previously undergone a bur hole procedure (p = 0.41, chi-square analysis). Thirty-five patients (16.7%) died in hospital, 130 were discharged to rehabilitation or a skilled care facility, and 44 returned home. The follow-up period extended to a maximum of 8.3 years (median 1.45 years). Six-month and 1-year mortality rates were 26.3% and 32%, respectively. In the multivariate analysis (step-wise logistic regression), the sole factor that predicted in-hospital death was neurological status on admission (OR 2.1, p = 0.02, for each step). Following discharge, the median survival in the remaining cohort was 4.4 years. In the Cox proportional hazards model, only age (hazard ratio [HR] 1.06/year, p = 0.02) and discharge to home (HR 0.24, p = 0.01) were related to survival, whereas the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate. Comparison of postdischarge survival and anticipated actuarial survival demonstrated a markedly increased mortality rate in the CSDH group (median survival 4.4 vs 6 years, respectively; HR 1.94, p = 0.0002, log-rank test). This excess mortality rate was also observed at 6 months postdischarge with evidence of normalization only at 1 year. Conclusions In this first report of the long-term outcome of elderly patients with CSDH the authors observed persistent excess mortality up to 1 year beyond diagnosis. This belies the notion that CSDH is a benign disease and indicates it is a marker of other underlying chronic diseases similar to hip fracture.

Download Full-text

Neurological and functional outcomes of subdural hematoma evacuation in patients over 70 years of age

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.118760 ◽

2013 ◽

Vol 04 (03) ◽

pp. 250-256 ◽

Cited By ~ 20

Author(s):

Patrick Mulligan ◽

Bethwel Raore ◽

Shuling Liu ◽

Jeffrey J Olson

Keyword(s):

Functional Status ◽

Subdural Hematoma ◽

Functional Outcomes ◽

The Elderly ◽

Neurological Status ◽

Common Disease ◽

Before And After ◽

Grading Scale ◽

Burr Holes

ABSTRACT Background: Subdural hematoma (SDH) is a common disease entity treated by neurosurgical intervention. Although the incidence increases in the elderly population, there is a paucity of studies examining their surgical outcomes. Objectives: To determine the neurological and functional outcomes of patients over 70 years of age undergoing surgical decompression for subdural hematoma. Materials and Methods: We retrospectively reviewed data on 45 patients above 70 years who underwent craniotomy or burr holes for acute, chronic or mixed subdural hematomas. We analyzed both neurological and functional status before and after surgery. Results: Forty-five patients 70 years of age or older were treated in our department during the study period. There was a significant improvement in the neurological status of patients from admission to follow up as assessed using the Markwalder grading scale (1.98 vs. 1.39; P =0.005), yet no improvement in functional outcome was observed as assessed by Glasgow Outcome Score. Forty-one patients were admitted from home, however only 20 patients (44%) were discharged home, 16 (36%) discharged to nursing home or rehab, 6 (13%) to hospice and 3 (7%) died in the postoperative period. Neurological function improved in patients who were older, had a worse pre-operative neurological status, were on anticoagulation and had chronic or mixed acute and chronic hematoma. However, no improvement in functional status was observed. Conclusion: Surgical management of SDH in patients over 70 years of age provides significant improvement in neurological status, but does not change functional status.

Download Full-text

Chronic Subdural Hematoma Spontaneous Resolution

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0037-1603512 ◽

2017 ◽

Vol 36 (02) ◽

pp. 096-100 ◽

Cited By ~ 1

Author(s):

Nícollas Rabelo ◽

Vitor Pereira ◽

George Santos dos Passos ◽

Luciano Silveira Filho ◽

André Cicilini ◽

...

Keyword(s):

Subdural Hematoma ◽

Elderly Population ◽

Temporal Evolution ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Spontaneous Resolution ◽

Exclusion Criteria ◽

Outer Capsule ◽

Bidirectional Flow

Introduction Chronic subdural hematoma (CSH) is a hemorrhagic brain injury that persists for more than 21 days after its initial formation. The incidence is predominantly among the elderly population (> 65 years), and varies from 58 to 74/100,000 inhabitants. Spontaneous resolution is considered variable; in the literature series, it is < 1–20% of cases. Objectives To expose the CSH pathophysiological mechanisms of spontaneous resolution and some treatments that lead to hematoma volume reduction. Methods Literature review between 1971 to 2016, using the PubMed, Medline, Embase, Scielo, LILACS and Cochrane databases using key-words, with inclusion and exclusion criteria. Discussion Spontaneous resolution of the CSH pathophysiology is controversial; however, it can be attributed to four basic mechanisms: 1) outer capsule membrane maturation; 2) decreased fibrinolysis; 3) bidirectional flow of blood vessels; and 4) platelet plug. Some drugs, such as mannitol, corticosteroids, tranexamic acid and atorvastatin, contribute to CSH resolution, since they change the capsule membrane permeability, and inhibit the fibrinolytic and inflammatory systems. Conclusion Spontaneous resolution is unpredictable; in some cases, it has a large temporal evolution (of up to 6 years). It occurs in small or laminar collections, asymptomatic or with transient neurological symptoms, and the pathophysiology is still controversial to this day. Therefore, surgical treatment should remain the first option, even though the conservative management is adopted for some patients. Rigorous outpatient and radiological follow-up are recommended.

Download Full-text

Chronic subdural hematoma: surgical management in 133 patients

Journal of Neurosurgery ◽

10.3171/jns.1984.61.2.0263 ◽

1984 ◽

Vol 61 (2) ◽

pp. 263-268 ◽

Cited By ~ 126

Author(s):

Richard G. Robinson

Keyword(s):

Subdural Hematoma ◽

Intracranial Hypotension ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Postoperative Management ◽

Content Type ◽

Brain Expansion ◽

Burr Holes ◽

Bilateral Lesions ◽

Active Policy

✓ One hundred and thirty-three patients with chronic subdural hematoma were treated surgically between 1943 and 1980. The patients, aged 5 to 84 years, were graded retrospectively according to the Bender scale; 28% were in Grades 3 and 4. There were 107 unilateral and 26 bilateral hematomas. The clots were removed mostly via burr-holes without drainage. The treatment of 121 patients included an active policy of brain expansion at operation and the postoperative management of intracranial hypotension by lumbar injection. Two patients died, for a mortality rate of 1.5%. The patients who died were 54 and 59 years old, both from among the 26 cases with bilateral lesions; 107 unilateral lesions were treated, with no deaths. None of 51 patients who were aged 61 years and over died. The mean postoperative stay was 17.2 days, and at 3 weeks 77% had been discharged home. Fifteen percent of survivors had permanent disabilities. The common residual deficits were personality and memory disorders, and there was hemiparesis in Grade 4 cases. The high-riskm groups of chronic subdural hematoma were those in Grades 3 and 4, bilateral hematomas, and the elderly. These seemed to be benefited by brain inflation and lumbar injections for intracranial hypotension.

Download Full-text

Relationship between supratentorial arachnoid cyst and chronic subdural hematoma: neuroradiological evidence and surgical treatment

Journal of Neurosurgery ◽

10.3171/2008.4.17509 ◽

2009 ◽

Vol 110 (6) ◽

pp. 1250-1255 ◽

Cited By ~ 33

Author(s):

Maurizio Domenicucci ◽

Natale Russo ◽

Elisabetta Giugni ◽

Alberto Pierallini

Keyword(s):

Arachnoid Cyst ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Ct Scanning ◽

Arachnoid Cysts ◽

Trauma Treatment ◽

Cranial Trauma ◽

Subdural Bleeding ◽

Mass Lesions

Object Arachnoid cysts are relatively common congenital intracranial mass lesions that arise during the development of the meninges. They can be complicated by the formation of an ipsilateral chronic subdural hematoma (CSDH) after minor cranial trauma. Treatment of these coexisting conditions remains controversial. In this study the authors describe the anatomical, clinical, and neuroradiological features and outcome in a series of patients whose CSDH associated with arachnoid cysts were managed surgically by draining the hematoma alone and leaving the cyst intact. The authors based this surgical management on histological and neuroradiological observations concerning these associated medical conditions. Methods A series of 8 patients with CSDHs associated with arachnoid cysts underwent surgery to drain the hematoma though a bur hole. The arachnoid cyst was left intact. Postoperative follow-up included CT scanning and T1- and T2-weighted MR imaging. Results Clinical, anatomical, and radiological observations suggest that because separate membranes cover arachnoid cysts and the related hematoma, arachnoid cysts remain unaffected by the subdural bleeding. In the present study, these observations received support from the neuroimaging appearances, suggesting that arachnoid cysts related to hematoma contained only blood breakdown products from the hematoma that had filtered through the reciprocal dividing membranes. Conclusions Arachnoid cysts associated with SDH are anatomically separate conditions whose neurological symptoms respond to surgical drainage of the CSDH alone.

Download Full-text

ACUTE SUBDURAL HEMORRHAGE AT BIRTH

PEDIATRICS ◽

10.1542/peds.14.5.468 ◽

1954 ◽

Vol 14 (5) ◽

pp. 468-474

Author(s):

RAYMOND SCHIPKE ◽

DAVID RIEGE ◽

WILLIAM B. SCOVILLE

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Significance ◽

Subdural Hematoma ◽

Early Recognition ◽

Chronic Subdural Hematoma ◽

Subdural Hemorrhage ◽

Subdural Bleeding ◽

Directing Attention

The term "acute subdural hemorrhage of the newborn" has been suggested for comparison with subarachnoid hemorrhage of the newborn and chronic subdural hematoma of infancy. Two cases of subdural hemorrhage in the newborn, treated by subdural drainage, are presented in detail. Five additional cases discovered at autopsy are discussed. Increased tension of the fontanelle is the most important single sign for directing attention to the possibility of subdural bleeding at birth. Early recognition as a prerequisite for favorable therapy is emphasized. Subdural bleeding of clinical significance is best demonstrated by coronal subdural taps.

Download Full-text

Incidence of surgery for chronic subdural hematoma in Finland during 1997–2014: a nationwide study

Journal of Neurosurgery ◽

10.3171/2021.3.jns21281 ◽

2021 ◽

pp. 1-8

Author(s):

Pihla Tommiska ◽

Teemu Luostarinen ◽

Jaakko Kaprio ◽

Miikka Korja ◽

Kimmo Lönnrot ◽

...

Keyword(s):

Subdural Hematoma ◽

Negative Binomial ◽

Age Groups ◽

Chronic Subdural Hematoma ◽

Case Fatality ◽

The Elderly ◽

European Standard Population ◽

Adjusted Incidence ◽

Age And Sex

OBJECTIVE The number of surgeries performed for chronic subdural hematoma (CSDH) has increased. However, these changes have been poorly reported. The authors aimed to assess the national incidence of surgeries for CSDH in Finland during an 18-year time period from 1997 to 2014. They hypothesized that the incidence of CSDH surgeries has continued to increase, particularly among the elderly. METHODS A nationwide register-based follow-up study was performed using the Finnish Care Register for Health Care. All adult patients undergoing primary CSDH surgeries during 1997–2014 were included. The study population was followed up from the time of CSDH surgery until death or the end of follow-up on December 31, 2017. The incidences of CSDH surgery per 100,000 person-years were calculated separately in each age group and sex. Age standardization was performed for those 20 years of age and older with weights from the 2013 European Standard Population. Negative binomial regression models were used to assess changes in incidence rate ratios (IRRs) during the study period. RESULTS In total, 9280 patients were identified. The age-standardized incidence of CSDH surgery increased from 12.2 to 16.5 per 100,000 person-years during 1997–2014. The age- and sex-adjusted incidence of CSDH surgery increased by 30% (IRR 1.30, 95% CI 1.20–1.41). The age- and sex-adjusted incidence increased more in the older age groups, with an IRR of 1.24 for those aged 60–69 years, 1.32 for those 70–79 years, 1.46 for those 80–89 years, and 1.85 for those aged 90 years or older. The adjusted incidence did not increase for those aged 18–59 years. The sex difference (2:1 men/women) was consistent throughout the study period, with a higher incidence among men. One year after the primary surgery, 19% of the population had a resurgery, and the 1-year case fatality rate was 15%. The median age of patients increased from 73 to 76 years. CONCLUSIONS During the past 2 decades, the age- and sex-adjusted incidence of CSDH surgery has increased in Finland, with major increases for those aged 60 years or older. This increase is likely to continue in parallel with the aging population and increased life expectancies.

Download Full-text