Development and validation of a recurrent prediction model for patients with unilateral chronic subdural hematoma without hematoma volumetric analysis.

OBJECTIVE: Approximately 10 % of patients with chronic subdural hematoma (CSDH) undergo reoperation after initial surgery. This study aimed to develop a predictive model for the recurrence of unilateral CSDH at initial surgery without hematoma volumetric analysis. METHODS: This single-center retrospective cohort study evaluated pre- and postoperative computed tomography (CT) images of patients with unilateral CSDH. The pre- and postoperative midline shift (MLS), residual hematoma thickness, and subdural cavity thickness (SCT) were measured. CT images were classified based on the internal architecture of the hematoma (homogenous, laminar, trabecular, separated, and gradation subtypes). RESULTS: Total 231 patients with unilateral CSDH underwent burr hole craniostomy. After receiver operating characteristic analysis, preoperative MLS and postoperative SCT showed better areas under the curve (AUCs) (0.684 and 0.756, respectively). According to the CT classification of preoperative hematomas, the recurrence rate was significantly higher in the separated/gradation group (18/97, 18.6 %) than in the homogenous/laminar/trabecular group (10/134, 7.5 %). Four-point score was derived from the multivariate model using the preoperative MLS, postoperative SCT, and CT classification. The AUC of this model was 0.796, and the recurrence rates at 0-4 points were 1.7 %, 3.2 %, 13.3 %, 25.0 %, and 35.7 %, respectively. CONCLUSION: Pre- and postoperative CT findings without hematoma volumetric analysis may predict CSDH recurrence.

Risk and prognostic factors of post-catheterization pseudoaneurysm.

PURPOSE: To evaluate the risk and prognostic factors of post-catheterization pseudoaneurysm (PPA). MATERIAL AND METHODS: To identify the risk factors for PPA occurrence, clinical findings were compared between 22 consecutive patients with radiologically confirmed PPAs (PPA group) and 300 randomly extracted patients without PPA, who underwent transarterial angiography or intervention (sample group) between 1 January 2015 and 31 March 2020. The PPA group was further divided into those treated successfully with mechanical compression (group A) and those requiring ultrasound-guided thrombin injection after compression failed (group B). Univariate and multivariate analyses were used to compare patient demographics, preoperative laboratory findings, procedure details, PPA diameter, and time interval between the procedure and compression between groups A and B to evaluate the prognostic factors of PPA. RESULTS: The PPA group demonstrated significantly elevated prothrombin time international normalized ratios (PT/INR) (odds ratio [OR]: 6.27, 95% confidence interval [CI]: 2.020-19.5; p = 0.00151) and more frequent popliteal access (OR: 14.2, 95% CI: 1.040-195.0; p = 0.0467) compared to the sample group, and radial access decreased the risk of PPA (OR: 0.382, 95% CI: 0.0148-0.987; p = 0.0468). One of the 22 PPAs resolved spontaneously, and 11 others (52.4%) were successfully treated by mechanical compression. An interval exceeding 24 hours between the procedure and compression was the only significant prognostic factor (p = 0.0281) between groups A and B. CONCLUSIONS: Elevated PT/INR and popliteal access may predispose patients to PPA; close consideration of the site of access may lower the risk of refractory PPA.

Modified Computed Tomography Classification for Chronic Subdural Hematoma Features Good Interrater Agreement: A Single-Center Retrospective Cohort Study.

OBJECTIVE: The present study aimed to establish whether our modified Nakaguchi computed tomography (CT) classification improves the interrater agreement of chronic subdural hematoma (CSDH) classification and prediction of CSDH recurrence relative to 2 other CT classifications. METHODS: This retrospective study considered 277 consecutive patients with CSDH and 307 hematomas treated with burr-hole surgery between January 2009 and December 2018. Two neurosurgeons blinded to patients' clinical data classified the CT scans of patients with CSDH into 4 or 5 types according to the Nomura classification (high, iso, low, mixed, and layering), Nakaguchi classification (homogenous, laminar, separated, and trabecular), and our modified Nakaguchi classification (homogenous, gradation, laminar, separated, and trabecular). The κ statistic was used to evaluate the interrater agreement of the 3 CT classifications. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for CSDH recurrence. RESULTS: κ values of the modified, Nakaguchi, and Nomura classification were 0.78, 0.63, and 0.70, respectively. During the 3 months follow-up, the recurrence rate for CSDH was 11.4% (35/307 hematomas). Of the types defined by the modified classification, the gradation type was associated with the highest recurrence (mean recurrence rate, 15.9% ± 0.3%). Multivariable logistic regression analyses showed that a gradation-type hematoma, as defined with the modified classification, was an independent risk factor associated with recurrence (odds ratio, 2.36; 95% confidence interval, 1.11-4.98; P = 0.025). CONCLUSIONS: The modified classification was useful for preoperative CT classification of CSDH and the prediction of recurrence, with high agreement between raters.

[Case of cerebral venous thrombosis causing refractory intracerebral hemorrhage].

Cerebral venous thrombosis is an uncommon disease characterized by expansive cerebral edema, venous infarction and massive intracerebral hemorrhage. Magnetic resonance imaging and angiography are useful for diagnosis of cerebral venous thrombosis. A 54-year-old man was admitted with headache, vomiting and right hemiparesis. Computed tomography (CT) revealed subcortical hematoma in the left parietal lobe. Digital subtraction angiography (DSA) demonstrated occlusion of the left Labbé vein with dilation of cortical veins and deep cerebral veins. He also suffered from pulmonary embolization and deep vein thrombosis in the lower extremities. Anticoagulant and thrombolytic agents were administered, then respiratory condition and hemiparesis were improved. However, his condition deteriolated 7 months after the initial attack. CT revealed huge subcortical hematoma in the same site. He underwent craniotomy and intracerebral hematoma was evacuated during treatment with vitamin K. His symptom gradually improved and he was discharged with moderate disability 2 months after operation. Dicision of surgical treatment is difficult because there is a risk of rebleeding due to thrombolytic therapy and progressive venous congestion. Since anticoagulant and thrombolytic therapy are inevitable, surgical indication for refractory intracerebral hemorrhage associated with cerebral venous thrombosis should be considered carefully.

[Serum S-100B protein and neuron-specific enolase after traumatic brain injury].

OBJECTIVE: The aim of this study was to investigate S-100B protein and NSE as a serum marker of brain cell damage after traumatic brain injury. MATERIAL AND METHODS: Forty-one patients with traumatic brain injury were included in this prospective study. Venous blood samples for S-100B protein and NSE were taken after admission and on the next day. Serum levels of S-100 protein and NSE were compared with Glasgow Coma Scale score, computed tomographic findings and outcome after 3 months. RESULTS: Serum S-100B protein and NSE were significantly correlated with Glasgow Coma Scale score and outcome after 3 months. The significant correlation was found between the initial S-100B and NSE (P < 0.001). In patients without parenchymal injuries on computed tomographic scan such as epidural hematoma and concussion, the elevation of S-100B protein and NSE was observed. The initial values of S-100B and NSE in acute subdural hematomas with unfavorable outcome were significantly higher than in those with favorable outcome. Secondary increase of serum markers was associated with the presence of secondary insult such as hypoxia or hypotension, and was found to have an unfavorable outcome. CONCLUSIONS: Serum concentration and kinetics of S-100B protein and NSE provide the clinical assessment of the primary brain damage and have a predictive value for outcome after traumatic brain injury.

[Acute spontaneous subdural hematoma of arterial origin].

BACKGROUND: Acute subdural hematoma is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. However, several cases of acute subdural hematoma without head injury (acute spontaneous subdural hematoma) have been reported. METHODS: Among 162 cases of acute subdural hematoma admitted to our departments between 1996 and 2003, we repoort eight cases of acute spontaneous subdural hematoma. These cases fulfilled the following criteria. 1) Head injury was either trivial or absent. 2) Neither aneurysm nor arteriovenous malformation was apparent. 3) CT scan revealed neither brain contusion nor traumatic subarachnoid hemorrhage. 4) At operation, laceration of the cortical artery was observed. In this article, we describe the clinical feature (age, sex, Glasgow Coma Scale [GCS] Score on admission, past history, CT appearance, and outcome) associated with this condition. RESULTS: Patients ranged in age from 68 to 85 years (average 74.8 years), and were comprised of 3 males and 5 females. Previous medical history included cerebral infarction in 6 of the 8 patients and myocardial infarction in 1 patient. These seven patients were taking antiplatelet manifestation. GCS on admission ranged from 4 to 13. Five of the 7 patients on antiplatelet medication had secondary insults, such as hypoxia. On CT, hematoma thickness ranged from 13.2mm to 42.5mm (average 22.6mm), and midline shift ranged from 10.0mm to 24.0mm (average 16.5mm). Neurological outcome evaluated using the Glasgow Outcome Scale was as follows, good recovery n = 2, moderate disability n = 2, severe disability n = 3, persistent vegetative state n = 1. CONCLUSION: The mechanism of acute spontaneous subdural hematoma is influenced by the presence of pre-existing cerebrovascular disease and by the use of antiplatelet agents. In such cases, the possibility of cortical arterial bleeding should be taken into account, and craniotomy should be performed.

[Progressive brain injury].

The aim of this study was to evaluate the clinical manifestations and prognostic factors of progressive brain injury following trauma. We reviewed the records of 779 patients with head injury who had an admission Glasgow Coma Scale of 9 or more; 70 (7.0%) developed progressive brain injury as evidenced on serial CT scans. Of these 70 patients, 19 (27.1%) had a subdural hematoma, 19 (27.1%) an epidural hematoma, 16 (22.9%) a cerebral contusion, 13 (18.6%) an intracerebral hematoma, and 3 (4.3%) a diffuse brain swelling. Three months after injury, 36 (51.4%) patients died, 2 (2.9%) were left in a vegetative state and 23 (32.9%) had a favorable outcome. The appearance of progressive brain injury was associated with patient age, admission Glasgow Coma Scale, injury mechanisms, skull fracture and hemorrhagic lesions on the initial CT scan. Patients with the extracerebral lesions deteriorated 4 hours after injury, whereas those with intracerebral lesions deteriorated 8 hours after injury. The outcome based on Glasgow Outcome Scale was significantly associated with age, type of intracranial lesion, Glasgow Coma Scale following deterioration, the mechanism of injury and surgical treatment. It is concluded that early repeated CT scan is indicated in patients with risk factors of developing progressive brain injury.