CT-Based Quantitative Analysis for Pathological Features Associated With Postoperative Recurrence and Potential Application Upon Artificial Intelligence: A Narrative Review With a Focus on Chronic Subdural Hematomas.

Chronic subdural hematomas (CSDHs) frequently affect the elderly population. The postoperative recurrence rate of CSDHs is high, ranging from 3% to 20%. Both qualitative and quantitative analyses have been explored to investigate the mechanisms underlying postoperative recurrence. We surveyed the pathophysiology of CSDHs and analyzed the relative factors influencing postoperative recurrence. Here, we summarize various qualitative methods documented in the literature and present our unique computer-assisted quantitative method, published previously, to assess postoperative recurrence. Imaging features of CSDHs, based on qualitative analysis related to postoperative high recurrence rate, such as abundant vascularity, neomembrane formation, and patent subdural space, could be clearly observed using the proposed quantitative analysis methods in terms of mean hematoma density, brain re-expansion rate, hematoma volume, average distance of subdural space, and brain shifting. Finally, artificial intelligence (AI) device types and applications in current health care are briefly outlined. We conclude that the potential applications of AI techniques can be integrated to the proposed quantitative analysis method to accomplish speedy execution and accurate prediction for postoperative outcomes in the management of CSDHs.

Headache in patients with chronic subdural hematoma: analysis in 1080 patients.

Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift. This clinical study was performed to identify the mechanism of headache in CSDH patients. We compiled clinical data of 1080 surgically treated CSDH patients (711 males and 369 females), and in 54 cases, the pressure of hematoma was measured during burr hole surgery using a glass-stick manometer. Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%. Ophthalmological examination was performed in 238 patients, and papilledema was identified in only one patient (0.4%). The mean age of patients with headache (59.8 ± 16.9 years) was significantly younger than that of those without (75.7 ± 11.2 years) (P < 0.01). In 54 cases, the mean hematoma pressure was not significantly different between patients with (17.1 ± 6.2 mmH2O) and without (18.4 ± 7.2 mmH2O) headache (P > 0.10). Hematoma thickness was significantly greater in patients without headache (P < 0.01), but the ratio of midline shift to hematoma thickness was significantly greater in patients with headache (P < 0.01). In our results, the status of increased intracranial pressure was rare in CSDH patients, and high hematoma pressure was not a cause of headache. Midline shift was the most influenced factor for headache in our study, and based on the results, the authors consider that the potential cause of headache in CSDH might be stretching or twisting of the pain-sensitive meninges and meningeal arteries or veins.

Simultaneous quantitative mapping of conductivity and susceptibility using a double-echo ultrashort echo time sequence: Example using a hematoma evolution study.

PURPOSE: The primary purpose of this study is to propose a method for the simultaneous quantitative three-dimensional (3D) mapping of conductivity and susceptibility using double-echo ultrashort echo time (UTE) imaging. The secondary purpose is to investigate the changes of these properties over time during in vitro hematoma evolution in blood samples. METHODS: The first and second set of echo data for a UTE sequence were used to perform quantitative conductivity mapping (QCM) and quantitative susceptibility mapping (QSM), respectively. A simulation study was conducted to determine the echo time (TE) range that was acceptable for QCM. Subsequently, a NaCl phantom experiment and in vivo 3D QCM and QSM demonstrations were performed. The changes in electromagnetic (EM) properties over time were studied using in vitro blood coagulation experiments with venous blood from healthy volunteers. RESULTS: Quantitative and qualitative analyses showed small differences in the QCM for TE values up to 300 µs. The estimated conductivity and susceptibility values monotonically increased during the first few hours of the hematoma evolution experiments. However, although the susceptibility values continued to increase, the conductivity values were steady after 24 h. CONCLUSION: The proposed method can be useful for determining EM property changes (including those during hemorrhage) and providing additional information about the state of the blood. Magn Reson Med 76:214-221, 2016. © 2015 Wiley Periodicals, Inc.

Postural stability in patients with chronic subdural hematoma.

BACKGROUND: Gait disturbances and falls are common in patients with chronic subdural hematoma (cSDH). Postural stability is mainly visually assessed and has not been described using an objective and quantitative measurement tool. The objective of this prospective study was to evaluate postural stability in cSDH patients by measuring trunk sway during stance and gait compared to healthy elderly (HE). It was also to evaluate the relationships among postural stability and age, hematoma size, brain midline shift and hematoma location. METHODS: Using a gyroscopic method, trunk sway was measured in 22 cSDH patients preoperatively, 5 postoperatively and 58 HE during seven standing and walking tasks. Trunk sway amplitude and velocity in the anterior-posterior and medial-lateral directions were assessed. RESULTS: Postural stability was reduced in the cSDH group compared to HE for all standing tasks. During gait, the sway angle was increased while velocity was decreased in the cSDH group. Only 18 % of the patients could perform all tasks without losing their balance. Postoperatively, postural stability was normalized in the medial-lateral direction during standing. There were no correlations among age, hematoma size, brain midline shift or location of the hematoma and trunk sway. CONCLUSIONS: The majority of cSDH patients had reduced postural stability that was partly reversed soon after surgery. It was not correlated to hematoma characteristics, indicating that an increased risk to fall is present regardless of hematoma size and midline shift. This must be accounted for when handling these patients and measures taken to prevent further fall accidents during hospital stays.

Spontaneous Resolution of Chronic Subdural Haematoma in a Patient Receiving Anticoagulant Therapy.

Significant chronic subdural hematoma (CSDH) is usually a surgical emergency. Spontaneous resolution of CSDH has rarely been reported in the literature. We are reporting a case of spontaneous resolution of CSDH in a patient receiving anticoagulant therapy who had undergone mitral valve replacement surgery.

Spontaneous resolution of nontraumatic chronic subdural hematoma associated with anti-aggregation therapy.

Spontaneous resolution of chronic subdural hematoma (CSDH) is rare, especially for the nontraumatic cases. Here, we present 1 case of a 70-year-old female patient with spontaneous resolution of CSDH. She was chronically anticoagulated after percutaneous coronary intervention. Moreover, she denied previous mild head trauma and bleeding episodes. For personal reasons, she declined surgery. Treatment just included mannitol, which was used to alleviate the symptoms. Intermittent computed tomography showed gradually resolution of CSDH. Spontaneous resolution of nontraumatic CSDH is rare, with different mechanisms and computed tomography characteristics compared with that of traumatic CSDH. Dimerized plasmin fragment D in venous blood may be more sensitive in the judgment of types of CSDH.

[CHRONIC SUBDURAL HEMATOMA: PHYSIOPATHOLOGY AND SURGICAL MANAGEMENT]. / HEMATOMA SUBDURAL CRONICO: FISIOPATOLOGIA Y MANEJO QUIRURGICO.

Chronic subdural hematoma is an encapsulated collection of blood underneath the Dura, essentially characterized by the presence of a membrane. It usually occurs in the elderly considered as a sentinel event. Simple brain computed tomography is the current imaging aid of choice for the diagnosis of this entity. It should be suspected especially in patients who present with dementia syndrome. Although less frequent, it should be investigated in patients with transient neurologic deficit. There is still no consensus regarding the ideal surgical modality of treatment. The procedure that seems most recommended is closed suction drainage through burr holes. It has been controversial whether intraoperative washing of such collection improves outcomes.

[Minimally invasive treatment of chronic subdural hematoma in adults. Results in 116 patients]. / Tratamiento mínimamente invasivo del hematoma subdural crónico del adulto. Resultados en 116 pacientes.

INTRODUCTION: Chronic subdural hematoma in adults (CSDH) has a global crude incidence of 14.1/100,000 per year in our institution captive population. There is no single treatment protocol. In our hospital we choose a minimal invasive technique (trans-marrow puncture) without general anaesthesia due to the age of the population. A descriptive study of patients with CSDH and treatment results, including a laterality analysis, is presented. MATERIAL AND METHODS: We retrospectively searched patients with (CSDH) between January 1998 and May 2009. The diagnosis was made by neuroimaging techniques in all patients. The preferred treatment was trans-marrow puncture; exceptionally some patients were treated by burr holes or craniotomy. RESULTS: We found 127 patients. Age, gender, midline displacement, hospitalisation days, and number of procedures, were not a predictive factor of mortality in the first month. A slight majority (55%) of CSDH were on the left side, with no statistically significant difference. There were 6 (4.7%) deaths during hospitalisation. In our series cumulative mortality at six months was 11.8%. Markwalder scale at admission was not a predictive factor of statistically significant mortality. An 80% of the patients received trans-marrow puncture as single procedure was performed on 80% of the patients. CONCLUSIONS: The results of our study suggest that trans-marrow puncture is an acceptable procedure, with low mortality, and less hospitalisation days and complications. Mortality, associated mechanisms, age, gender, midline displacement are no different than in others previous publications. We found a higher frequency of hematomas to the left, as in other series. Meta-analysis studied need to be performed to determine more accurately the frequency of this dominance.

Use of twist-drill craniostomy with drain in evacuation of chronic subdural hematomas: independent predictors of recurrence.

BACKGROUND: Recurrence rates after chronic subdural hematoma (CSDH) evacuation with any of actual techniques [twist-drill craniostomy (TDC), burr-hole craniostomy, craniotomy] range from 5% to 30%. Use of drain has improved recurrence rates when used with burr-hole craniostomy. Now, we analyze predictors of recurrence of TDC with drain. METHOD: Three hundred twelve consecutive patients with CSDH have been studied in a retrospective study. Operative technique in all patients consisted in TDC with drain. Data recorded included any associated comorbidity. Radiologic measures of the CSDH before and after the procedure were studied. Clinical evaluation included Modified Rankin Scale, Glasgow Coma Scale (GCS), and neurological deficits. Two groups were compared: recurrence group and nonrecurrence group. Follow-up was for at least 1 year. RESULTS: Twelve percent experienced recurrence. Preoperative CSDH width, preoperative midline shift, postoperative midline width, postoperative CSDH width, and residual CSDH 1 month later were significantly associated with CSDH recurrence. The logistic regression model for the multivariate analysis revealed that postoperative midline shift and postoperative neurological deficit were significantly associated with CSDH recurrence. The duration of treatment with dexamethasone was found not to be related with recurrence. Mortality before hospital discharge was 1%. Hospital stay was 2.5 days. CONCLUSIONS: TDC with drain has similar results in recurrence rates, morbidity, mortality, and outcome as other techniques as burr-hole craniostomy with drain. Preoperative and postoperative hematoma width and midline shift are independent predictors of recurrence. Brain re-expansion and time of drain maintenance are important factors related with recurrence of CSDH. Future CSDH reservoirs must avoid negative pressure and sudden pressure changes inside the whole closed drain system.

Paradigms in chronic subdural hematoma pathophysiology: Current treatments and new directions.

ABSTRACT: Chronic subdural hematomas (CSDHs) are an increasingly common pathology encountered in a neurosurgical trauma practice. Although the operative and nonoperative management of CSDH has been studied extensively, the recurrence rate of CSDH remains high, with no significant decrease in recent years. We undertook a detailed assessment of the known pathophysiological mechanisms by which CSDHs recur to improve our ability to treat patients with this disease successfully. In this review of the literature from the PubMed and Scopus databases, we used the search terms "(pathophysiology) AND chronic subdural hematoma [tiab]" to identify pertinent reviews and articles in English. The results demonstrated a complex inflammatory response to subdural blood, which begins with the formation of a collagen neomembrane around the clot itself. Proinflammatory mediators, such as vascular endothelial growth factor, interleukin-6, interleukin-8, tissue necrosis factor α, matrix metalloproteinases, and basic fibroblast growth factor, then contribute to chronic microbleeding by promoting the formation of fragile, leaky blood vessels, and widening of gap junctions of existing vessels. It is evident that the lack of improvement in recurrence rate is due to pathological factors that are not entirely alleviated by simple subdural evacuation. Targeted approaches, such as middle meningeal artery embolization and anti-inflammatory therapies, have become increasingly common and require further prospective analysis to aid in the determination of their efficacy.

Accelerated hemolysis and neurotoxicity in neuron-glia-blood clot co-cultures.

A growing body of experimental evidence suggests that an intracerebral hematoma is toxic to neighboring cells. However, injury mechanisms remain largely undefined, due in part to conflicting results from in vivo studies. In order to investigate blood toxicity in a more controlled environment, murine clots were co-cultured on porous membrane inserts with primary neurons and glia. Erythrocyte lysis was apparent within 48 h, but was reduced by almost 80% in cultures lacking neurons, and by over 90% in the absence of both neurons and glial cells. By 72 h, most released hemoglobin had oxidized to methemoglobin or its hemichrome degradation products. At this time point, approximately 50% of neurons were non-viable, as detected by propidium iodide staining; glia were not injured. Deferoxamine, Trolox and the NMDA receptor antagonist MK-801 prevented most neuronal death, but had no effect on hemolysis at neuroprotective concentrations. The 27-fold increase in culture malondialdehyde and 5.8-fold increase in heme oxygenase-1 expression were also attenuated by deferoxamine and Trolox, but not by MK-801. These results suggest that hemoglobin release from clotted blood is accelerated by adjacent neurons and glia. Subsequent neurotoxicity is mediated by both iron-dependent and excitotoxic injury pathways.

Chronic sub-dural hematomas: twist drill craniostomy with a closed system of drainage, for 48 hours only, is a valuable surgical treatment.

Twist drill craniostomy with closed drainage system for 48-hour duration is an effective treatment of chronic subdural hematomas.

Treatment of chronic subdural haematomas - a retrospective comparison of minicraniectomy versus burrhole drainage.

Primary chronic subdural haematomas remains one of the commonest conditions managed by neurosurgeons. Despite this there is a relative lack of evidence regarding best management and certain treatments such as minicraniectomy, have rarely been assessed in the literature. A retrospective case note review comparing minicraniectomy and burrhole drainage of primary chronic subdural haematoma was therefore performed. We sought to determine the proportion of patients requiring repeat drainage or dandy cannula aspiration following initial surgery and to assess outcome at outpatient follow-up. The mean age of patients undergoing minicraniectomy was 73, compared to 63 in the burrhole group (p < 0.001). 130 patients underwent burrhole drainage, 23 of whom (18%) developed a symptomatic recurrence. 21 (16%) of these patients required repeat drainage. Of the 116 patients who underwent a craniectomy 23 (20%) patients suffered a symptomatic recurrence. 15 (13%) patients required the minicraniectomy to be reopened for further washout (p = 0.48). (8%) patients who underwent burrhole drainage died compared to 20 (17%) patients following craniectomy (95%CI 2 to 18%; p = 0.03). However, controlling for age using logistic logression, showed no significant difference between the two treatment groups in recurrence (p = 0.28) or death (p = 0.06). Craniectomy may be considered as a treatment option particularly in the elderly population and in patients with multiple loculated collections.

Working toward rational and evidence-based treatment of chronic subdural hematoma.

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions that can usually be treated with relatively simple and effective surgical procedures. It affects primarily the elderly, a rising population worldwide. Together with improved awareness among the medical profession and greater access to modern imaging facilities, the incidence of CSDH is set to rise significantly. Maximization of the efficiency of management of CSDH is therefore a priority. To this end, a review of the findings of clinical and laboratory research underpinning the basis of the modern management of CSDH has been carried out. This review focuses on the pathophysiology and briefly discusses the epidemiology, clinical presentation, and surgical treatments of CSDH, concluding that a one-for-all management strategy is not appropriate. Creating rational bases for the selection of an ideal treatment strategy for an individual patient should be the target. This can be achieved through better understanding of the nature of the condition through systematic basic science research, ascertaining the merits of different surgical techniques in well-designed and rigorously executed clinical trials, using advances in imaging techniques to classify CSDH (a subject not addressed here), and training in and ongoing refinement of clinical acumen and surgical skills of individual surgeons.

DynaCT Enhancement of Subdural Membranes After Middle Meningeal Artery Embolization: Insights into Pathophysiology.

OBJECTIVE: Middle meningeal artery (MMA) embolization could be an effective method of inhibiting neovascularization of the subdural capsular membrane and preventing hematoma maintenance. We sought to better understand how the MMA might affect subdural hematoma physiology and how this process might be modified by embolization. METHODS: We performed a retrospective review of 27 patients with 29 subdural hematomas (SDHs) who had undergone MMA embolization from July 2018 to May 2019. Of the 27 patients, 8 had undergone postembolization DynaCT imaging studies and were included in the present study. RESULTS: The average patient age was 75 years. The baseline noncontrast-enhanced cranial computed tomography (CT) scans showed the presence of a hematoma membrane in all 8 patients. The postembolization DynaCT scans of all patients demonstrated enhancement of all 4 components (i.e., dura, capsular membrane, septations, and subdural hematoma fluid). All patients had a minimum of 60-day imaging and clinical follow-up data available. The average decrease in SDH volume at the last follow-up examination was 87% compared with that at baseline. A significant difference was found between the average baseline and average last follow-up SDH volume (P < 0.0001, paired t test) in all 8 patients. The average interval from the date of the procedure to the last follow-up scan was 89 days (range, 61-122 days). No patient experienced postembolization complications, subsequent SDH drainage, or mortality. CONCLUSIONS: Our data lend support to the theory of contiguous vascular networks between the MMA and SDH membranes. Targeting these leaky vascular networks might remove the source of hematoma accumulation. These data add to the pathophysiological understanding of the disease and suggests potential insights into the mechanism of action of MMA embolization.

Is there an interest in performing a systematic CT scan within the first two months after chronic subdural hematoma evacuation? A ten-year single-center retrospective study.

OBJECTIVES: The aims of the present study were to evaluate the frequency of late recurrence after chronic subdural hematoma (CSDH) evacuation and to examine the interest in the use of a systematic CT scan within the first two months after surgery. PATIENTS AND METHODS: We performed a retrospective study that included all patients who underwent CSDH evacuation between 2007 and 2017. We evaluated the rate of late recurrence, defined as the need to perform a new surgery after the first month of follow-up. All the patients underwent a clinical examination and a systematic CT scan between one and 2 months after the first surgery (delayed systematic CT scan). We evaluated the rate of clinical recurrence, defined as the association between clinical symptoms and radiological abnormalities, and of radiological recurrence, defined only on CT scan data. RESULTS: During the inclusion period, 696 patients underwent CSDH evacuation in our unit. Overall, 54 patients (7.7%) had recurrence, of whom 21 (39%) had recurrence after 4 weeks (late recurrence). Of the 21 patients with late recurrence, 7 (1%) had radiological recurrence, and 14 (2%) had clinical recurrence. There was no difference in the CT scan characteristics between patients with clinical and radiological recurrence. CONCLUSION: The use of a delayed systematic CT scan after CSDH surgery has a marginal impact on patient management, and the indication for reoperation without symptoms seems highly subjective. In patients without neurological symptoms, the use of a delayed cerebral CT scan may not be indicated.