Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta-analysis.

Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access-site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random-effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40-0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38-0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32-0.53, p < 0.00001], and shortens fluoroscopy time [SMD: -0.62; 95% CI: -1.00 to -0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: -0.33; 95% CI: -0.61 to -0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30-day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large-scale randomized controlled trials are warranted to confirm and strengthen these findings.

Beyond biventricular pacing: Exploring the advantages of his-bundle pacing and left bundle branch pacing in heart failure-A systematic review and meta-analysis.

BACKGROUND: This meta-analysis compares His-Purkinje system pacing (HPSP), a novel cardiac resynchronization therapy (CRT) technique that targets the intrinsic conduction system of the heart, with conventional biventricular pacing (BiVP) in heart failure (HF) patients with left ventricular (LV) dysfunction and dyssynchrony. METHODS: We searched multiple databases up to May 2023 and identified 18 studies (five randomized controlled trials and 13 observational studies) involving 1291 patients. The outcome measures were QRS duration, left ventricular ejection fraction (LVEF) improvement, left ventricular end-diastolic diameter (LVEDD) change, HF hospitalization, and New York Heart Association (NYHA) functional class improvement. We used a random-effects model to calculate odds ratios (OR), and mean differences (MD) with 95% confidence intervals (CI). We also assessed the methodological quality of the studies. RESULTS: The mean LVEF was 30.7% and the mean follow-up duration was 8.1 months. Among LBBP, HBP, and BiVP, HBP provided the shortest QRS duration [MD: -18.84 ms, 95% CI: -28.74 to -8.94; p = 0.0002], while LBBP showed the greatest improvement in LVEF [MD: 5.74, 95% CI: 2.74 to 7.46; p < 0.0001], LVEDD [MD: -5.55 mm, 95% CI: -7.51 to -3.59; p < 0.00001], and NYHA functional class [MD: -0.58, 95% CI: -0.80 to --0.35; p < 0.00001]. However, there was no significant difference in HF hospitalization between HPSP and BiVP. CONCLUSION: LBBP as modality of HPSP demonstrated superior outcomes in achieving electrical ventricular synchrony and systolic function, as well as alleviating HF symptoms, compared to other pacing techniques.

Association of gut microbiome dysbiosis with the progression of atrial fibrillation: A systematic review.

OBJECTIVE: Many clinical and preclinical studies have implicated an association between atrial fibrillation (AF) and its progression to imbalances in the gut microbiome composition. The gut microbiome is a diverse and complex ecosystem containing billions of microorganisms that produce biologically active metabolites influencing the host disease development. METHODS: For this review, a literature search was conducted using digital databases to systematically identify the studies reporting the association of gut microbiota with AF progression. RESULTS: In a total of 14 studies, 2479 patients were recruited for the final analysis. More than half (n = 8) of the studies reported alterations in alpha diversity in atrial fibrillation. As for the beta diversity, 10 studies showed significant alterations. Almost all studies that assessed gut microbiota alterations reported major taxa associated with atrial fibrillation. Most studies focused on short-chain fatty acids (SCFAs), whereas three studies evaluated TMAO levels in the blood, which is the breakdown product of dietary l-carnitine, choline, and lecithin. Moreover, an independent cohort study assessed the relationship between phenylacetylglutamine (PAGIn) and AF. CONCLUSION: Intestinal dysbiosis is a modifiable risk factor that might provide newer treatment strategies for AF prevention. Well-designed research and prospective randomized interventional studies are required to target the gut dysbiotic mechanisms and determine the gut dysbiotic-AF relationship.

Impact of trans-anal versus laparoscopic total mesorectal excision on the surgical and pathologic outcomes of patients with rectal cancer: meta-analysis of randomized controlled trials.

BACKGROUND: Despite its profound impact on the oncologic outcomes of rectal cancer, the most optimal surgical approach to total mesorectal excision (TME) has not been identified yet. All previous meta-analyses on this subject have been based on observational studies. This meta-analysis was conducted to assess the surgical and oncologic outcomes of laparoscopic TME (LaTME) compared to trans-anal TME (TaTME), utilizing only randomized controlled trials. DESIGN: Systematic review and meta-analysis of randomized controlled trials. METHODS: We searched electronic databases (MEDLINE, Cochrane CENTRAL, Clinicaltials.gov) from 2010 onwards, for all published clinical trials comparing TaTME to LaTME. Results are presented as risk ratios, with 95% CI, and pooled using the random effects model. RESULTS: A total of 1691 patients, from 6 eligible randomized controlled trials, were included for analysis. Analyzed data showed no significant difference in morbidity (RR: 0.85, p = 0.15), mortality (RR: 0.50, p = 0.44), conversion to open (RR: 0.40, p = 0.07), or anastomotic leakage (RR: 0.73, p = 0.10) between TaTME and LaTME. There was also no difference in the rate of positive distal resection margin (DRM) (RR: 0.55, p = 0.10) or positive circumferential resection margin (CRM) (RR: 0.67, p = 0.30). Patients undergoing TaTME were more likely to have a complete TME (RR: 1.06, p = 0.002) and shorter hospital stays (RR: - 0.97, p < 0.00001). CONCLUSIONS: Patients undergoing TaTME for rectal cancer were more likely to have a complete TME when compared to LaTME, though this did not translate into improved distal or circumferential resection margin. Additionally, TaTME and LaTME had similar surgical outcomes except for shorter length of stay with TaTME.

Direct Oral Anticoagulants Exhibit Lower Risks of Mortality and Bleeding Compared to Vitamin K Antagonists in Atrial Fibrillation Patients on Chronic Hemodialysis: A Systematic Review and Meta-Analysis.

This meta-analysis aimed to assess the outcomes of patients with atrial fibrillation undergoing chronic hemodialysis, comparing the effectiveness of direct oral anticoagulants (DOACs) and vitamin K antagonists. A systematic search was conducted across various databases including PubMed, Embase, and Google Scholar. Efficacy outcomes focused on the risk of stroke and mortality, whereas safety outcomes assessed the risk of bleeding. Review Manager generated forest plots for data synthesis. Statistical significance was set at P < 0.05, and random-effects models were used. Subgroup analysis identified the sources of heterogeneity. Nine studies met the inclusion criteria for the final analysis. The risk of all-cause stroke [risk ratio (RR): 0.64; 95% confidence interval (CI): 0.51-0.81; P = 0.0001; I2 = 0%], ischemic stroke (RR: 0.53; 95% CI: 0.29-0.96; P = 0.04; I2 = 0%), all-cause mortality (RR: 0.73; 95% CI: 0.60-0.88; P = 0.001; I2 = 71%), major bleeding (RR: 0.63; 95% CI: 0.52-0.76; P < 0.00001; I2 = 44%), gastrointestinal bleeding (RR: 0.67; 95% CI: 0.53-0.85; P = 0.0009; I2 = 36%), intracranial hemorrhage (RR: 0.57; 95% CI: 0.38-0.84; P = 0.004; I2 = 0%) were lower in the DOAC group compared with the vitamin K antagonist group. The risk of cardiovascular-related death (RR: 1.34; 95% CI: 0.69-2.60; P = 0.39; I2 = 0%), clinically relevant nonmajor bleeding (RR: 0.90; 95% CI: 0.75-1.08; P = 0.26; I2 = 28%), and hemorrhagic stroke (RR: 0.36; 95% CI: 0.06-2.24; P = 0.28; I2 = 10%) showed no significant differences. In conclusion, the risks of all-cause stroke, ischemic stroke, all-cause mortality, major bleeding, gastrointestinal bleeding, and intracranial hemorrhage in patients with atrial fibrillation undergoing chronic hemodialysis were lower in the DOAC group.

Precision medicine in Myocardial Infarction With Non-obstructive Coronary Disease (MINOCA): A comprehensive review.

Cardiovascular diseases, particularly myocardial infarction (MI), are a significant cause of mortality globally. Traditional MIs are commonly linked to substantial coronary artery blockage. However, a distinct subset of patients experience MI with non-obstructive coronary arteries, known as MINOCA. Imaging techniques, such as invasive coronary angiograms, are employed to diagnose MI or assess predisposition to one. Coronary angiograms help visualize vessel blockages; however, these blockages are absent in MINOCA cases, posing a diagnostic challenge. Precision medicine aims to introduce new diagnostic tools to assist in early diagnosis and further management of MINOCA. As percutaneous coronary intervention (PCI) does not benefit MINOCA patients, medical management tailored to the specific pathophysiological mechanism of MINOCA is employed. For example, if MINOCA is attributed to plaque disruption with or without plaque thrombus formation, the fundamental treatments may include statins, agents that modulate the renin-angiotensin system (RAS), and antiplatelet therapies. On the other hand, if coronary artery spasm is identified as the primary cause, essential intervention involves the use of calcium channel blockers. This approach has been previously utilized in patients with vasospastic angina and could be utilized in MINOCA, although research specific to MINOCA is ongoing. Therefore, the handling of MINOCA underscores the necessity for a tailored therapeutic strategy that corresponds to the underlying physiological mechanism responsible for the patient's clinical symptoms. Ongoing research initiatives are directed at expanding the availability of these treatments, uncovering new biomarkers, creating advanced diagnostic instruments, and establishing a more individualized approach for managing MINOCA patients.

The impact of chronic total occlusion in non-infarct related arteries on patient outcomes following percutaneous coronary intervention for STEMI superimposed with cardiogenic shock: A pilot systematic review and meta-analysis.

INTRODUCTION: Chronic total occlusion (CTO) is defined as a near-total blockage of a coronary artery and often occurs in arteries that are not directly responsible for the event, known as non-infarct-related arteries (NIRA). Cardiogenic shock (CS) is a complication of ST-elevated myocardial infarction (STEMI) that carries significant mortality. We performed a meta-analysis to find an association between mortality in patients undergoing PCI for STEMI that have superimposed CS, with the presence of CTO in the NIRA. MATERIALS AND METHODOLOGY: A comprehensive literature search was conducted using PubMed, EMBASE, Google Scholar and clinicaltrials.gov from inception till October 2023 to retrieve studies that compare the presence of CTO with the absence of CTO in NIRA in STEMI with CS patients undergoing PCI. The primary endpoint was 30-day mortality and the secondary endpoints were risk of all-cause mortality (ACM) and repeat myocardial infarction (MI). Forest plots were generated using the random effects model by pooling odds ratios (ORs) with a 95 % confidence interval. Statistical significance was set at p < 0.05. RESULTS: 5 observational studies with a total of 5186 patients (1031 with CTO in NIRA and 4155 with no CTO in NIRA) were included. The presence of CTO in NIRA was associated with higher odds of 30-day mortality [OR: 3.10; 95 % CI: 1.52, 6.32; p < 0.002], and ACM [OR: 2.37; 95 % CI: 1.83, 3.08; p < 0.00001]. The odds of repeat MI were comparable between the two groups [OR: 1.61, 95 % CI: 0.03, 74.36, p = 0.81]. CONCLUSIONS: The presence of CTO in the NIRA serves as an independent indicator of unfavorable clinical outcomes including increased risk of 30-day mortality and all-cause mortality. The risk of repeat MI was comparable between the two groups. Large-scale, multicenter trials are warranted to identify the most effective management approach for these patients.

Exploring Acute Kidney Injury Following Aortic Dissection: A Comprehensive Review of Machine Learning Models for Predicting Risk, Management Strategies, Complications, and Racial and Gender Disparities.

Both types of aortic dissection (AD), Stanford type A and type B, can result in complications such as acute kidney injury (AKI) and aortic rupture. Renal complications in AD arise from compromised renal perfusion affecting the renal arteries. Understanding the intricate connection between AD and AKI is crucial for navigating the complexities of tailored treatment and formulating specific management plans. Concerning machine learning models, in patients with type A aortic dissection, factors such as decreased platelet count on admission, increased D-dimer level, longer cardiopulmonary bypass duration, elevated white blood cell levels, the need for blood transfusion, longer aortic clamp time, extended surgery duration, advanced age, and an elevated body mass index were positively associated with the development of AKI. For the risk of AKI after type B aortic dissection, elevated Nt-pro brain natriuretic peptide, prolonged activated partial thromboplastin time, elevated admission systolic blood pressure, and a higher contrast agent requirement during operative repair were found to predict the risk. Male gender was associated with a higher risk of AKI, and nonwhite race was linked to a higher risk of AKI, a greater likelihood of requiring more urgent procedures, and lower levels of insurance coverage. The treatment of AKI following AD requires a multifaceted approach. Identifying and addressing the underlying cause, such as low blood pressure, renal artery involvement, or medication-induced injury, is crucial for effective management and preventing further kidney damage. Maintaining proper fluid balance is essential for improving renal perfusion, but careful monitoring is necessary to avoid complications. The evolving landscape of research, particularly in biomarkers and AI programs, reveals a promising role in predicting the risk for and managing AKI post-AD.

Comparison of Outcomes Between Right and Left Upper Extremity Access in Endovascular Aortic Repair for Patients with Thoracoabdominal and Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis.

Traditionally, left-sided upper extremity (LUE) access has been preferred in patients undergoing endovascular aortic repair (EVAR) to manage aortic aneurysms and decrease the risk of cerebrovascular adverse events. Recently, right-sided upper extremity access (RUE) has gained popularity owing to its greater maneuverability and ergonomics. However, synthesized data comparing the safety and efficacy of RUE and LUE accesses are limited. A comprehensive literature search was conducted on various databases from inception to September 2023 to retrieve all studies that compared RUE and LUE access in EVAR. Data on stroke, 30-day mortality, technical success, access-site complications, total time required for fluoroscopy, and contrast agent requirement were extracted, pooled, and analyzed. Forest plots were generated using a random-effects model on review manager by pooling the risk ratios (RRs) and standard mean differences (SMDs). Ten observational studies with a total of 3994 patients were included in our analysis with 1186 patients in the RUE and 2808 patients in the LUE access groups. EVAR using RUE access was associated with a significantly lower amount of contrast agent requirement than the LUE access group [SMD, -0.23; 95% confidence interval (CI), -0.45 to -0.02; P = 0.03]. There was no significant difference between the 2 groups in terms of the risk of stroke (RR, 1.62; 95% CI, 0.81-3.22; P = 0.17), 30-day mortality (RR, 1.42; 95% CI, 0.50-4.06; P = 0.51), rate of technical success (RR, 0.98; 95% CI, 0.95-1.01; P = 0.18), risk of access-site complications (RR, 1.00; 95% CI, 0.72-1.39; P = 0.99), and total time required for fluoroscopy (SMD, 0.07; 95% CI, -0.39 to 0.26; P = 0.69). The use of RUE access in EVAR appears to be comparable to LUE access in terms of the risk of stroke, access-related complications, all-cause mortality, technical success rate, and fluoroscopy duration. The RUE group required a lower volume of contrast agent.

Efficacy and Safety of Pressure-controlled Intermittent Coronary Sinus Occlusion in STEMI: A Systematic Review and Meta-analysis.

This systematic review will provide a comprehensive assessment of the evidence on PICSO in STEMI patients, and it will help to determine the role of this novel technique in the management of STEMI. The review searched for the relevant articles in the PubMed, Embase, Cochrane Library, and Web of Science databases regarding PC-ICSO. Four cohort studies were eligible to be included in the quantitative analysis. In the pooled analysis, the use of PICSO was associated with a significant reduction in infarct size (SMD = -0.44, 95% CI = -0.76,-0.13, p = 0.004). PICSO administration was associated with a reduced risk of developing microvascular resistance (RR = 0.75, 95% CI = 0.62,0.92, p = 0.0051). The post-procedural Index of Microvascular Occlusion (MVO) was lower in the PICSO treated compared to the control group and this result was homogenous and statistically significant (SMD = -0.35, 95% CI = -0.68-0.01, p = 0.03, I2 = 0%). Compared to matched controls, the use of PICSO was associated with higher Left Ventricular Ejection Fraction (LVEF) at the longest follow-up (SMD = 0.328, 95% CI = 0.03, 0.06, p = 0.03, I2 = 0%). This review suggested that PICSO can be used during PPCI in STEMI with improved outcomes of infarct size, LVEF, and microvascular perfusion.

Evaluating the role of ivabradine in acute decompensated heart failure: A systematic review and meta-analysis.

BACKGROUND: Acute decompensated heart failure (ADHF) presents a significant global health challenge, with high morbidity, mortality, and healthcare costs. The current therapeutic options for ADHF are limited. Ivabradine, a selective inhibitor of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, has emerged as a potential therapy for ADHF by reducing the heart rate (HR) without negatively affecting myocardial contractility. However, the evidence regarding the efficacy and safety of ivabradine in patients with ADHF is limited and inconsistent. This meta-analysis aimed to evaluate the efficacy and safety of ivabradine for ADHF based on observational studies. METHODS: A systematic literature search was conducted following PRISMA guidelines to identify relevant observational studies comparing ivabradine with placebo in adult patients with ADHF. Data were pooled using a random-effects model, and heterogeneity was assessed. The risk of bias was evaluated using the Newcastle-Ottawa Scale. RESULTS: Four observational studies comprising a total of 12034 patients. Meta-analysis revealed that ivabradine significantly reduced all-cause mortality (RR: 0.66, 95 % CI: 0.49-0.89, p < 0.01) and resting HR (MD: -12.54, 95 % CI: -21.66-3.42, p < 0.01) compared to placebo. However, no significant differences were observed in cardiovascular mortality, hospital readmission for all causes, changes in LVEF, or changes in LVEDD. Sensitivity and publication bias assessments were conducted for each outcome. CONCLUSION: Ivabradine may be beneficial for reducing mortality and HR in patients with ADHF. However, its impact on other clinical outcomes such as cardiovascular mortality, hospital readmission, and cardiac function remains inconclusive. Further research, particularly well-designed RCTs with larger sample sizes and longer follow-up durations, are warranted.

Bevacizumab Combination Therapy Versus Standard Chemotherapy for Ovarian Cancer in Shorter and Longer Follow-Up Duration: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: This systematic review and meta-analysis aims to evaluate the efficacy and safety of bevacizumab in patients with ovarian cancer over a shorter and longer follow-up period. METHODS: We searched Medline, Cochrane CENTRAL, Scopus, and Google Scholar for all phase 3 randomized controlled trials (RCTs) that administered bevacizumab to women with ovarian cancer. Review Manager 5.4 was used to calculate risk ratios (RR) and hazard ratios (HR) with 95% CIs. We assessed the quality of the included studies using version 2 of the Cochrane Risk of Bias tool (RoB 2). RESULTS: After screening the titles, abstracts, and full texts, we included nine RCTs in our systematic review and meta-analysis. Four RCTs had a low risk of bias, while 5 had some concerns. Bevacizumab was associated with a progression free survival benefit for <36 months (HR: 0.59, 95% CI: 0.45-0.76, P<0.0001, I2=90%) and >36 months (HR: 0.66, 95% CI: 0.55-0.80, P<0.0001, I2=80%), and an overall survival benefit for <36 months (HR: 0.87, 95% CI: 0.78-0.98, P=0.02, I2=0%) but not for >36 months (HR: 0.98, 95% CI: 0.89-1.09, P=0.77, I2=30%). There was no difference in deaths between intervention and control groups <36 months (RR: 0.95, 95% CI: 0.86-1.04, P=0.26, I2=10%) or >36 months (RR: 1.02, 95% CI: 0.97-1.06, P=0.50, I2=0%). Bevacizumab reduced disease progression <36 months (RR: 0.82, 95% CI: 0.72-0.92, P=0.0008, I2=82%) but not at >36 months (RR: 0.83, 95% CI: 0.58-1.19, P=0.30, I2=94%). The adverse events reported with Bevacizumab use included thrombocytopenia, neutropenia, leukocytopenia, anemia, hypertension, bleeding or hemorrhage, and gastrointestinal, cardiac, and dermatological adverse events. CONCLUSION: Bevacizumab may improve progression-free survival within and after 36 months, overall survival within 36 months, and reduce disease progression within 36 months.

Unveiling the relationship between gut microbiota and heart failure: Recent understandings and insights.

Gut microbiota, which comprises a broad range of bacteria inhabiting the human intestines, plays a crucial role in establishing a mutually beneficial relationship with the host body. Dysbiosis refers to the perturbations in the composition or functioning of the microbial community, which can result in a shift from a balanced microbiota to an impaired state. This alteration has the potential to contribute to the development of chronic systemic inflammation. Heart failure (HF) is a largely prevalent clinical condition that has been demonstrated to have variations in the gut microbiome, indicating a potential active involvement in the pathogenesis and advancement of the disease. The exploration of the complex interplay between the gut microbiome and HF presents a potential avenue for the discovery of innovative biomarkers, preventive measures, and therapeutic targets. This review aims to investigate the impact of gut bacteria on HF.

Coronary Stent Infection: A Systematic Review of Literature.

Coronary stent infection is a rare yet serious complication of coronary artery stenting, with potentially significant morbidity and mortality. This systematic review aimed to comprehensively assess the available evidence on the diagnosis, management, and outcomes of coronary stent infection. A comprehensive search of electronic databases, including PubMed, Embase, Cochrane Library, and Scopus, was conducted from inception until March 2023, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 1 case series and 41 case reports, covering a cumulative sample size of 44 patients, were included in the analysis. The predominant stent types were drug-eluting stents in 22 studies, bare-metal stents in 3 studies, and a combination of drug-eluting stents and bare-metal stents in 4 studies. Staphylococcus aureus was the predominant identified organism in microbiological profiles. Primary outcomes, including mortality, morbidity, and recurrence rates, were evaluated. The aggregate mortality rate across studies was 18%, underscoring the severity of coronary stent infections. Morbidity ranged from 3% to 60%, with a spectrum of complications such as sepsis, heart failure, and embolic events. Recurrence rates varied from 3% to 33%, emphasizing the importance of effective management. Treatment strategies encompassed antibiotics alone, antibiotics with stent removal, and antibiotics with stent retention, with the duration of antibiotic therapy ranging from 2 weeks to 12 months. The optimal management strategy remains uncertain due to limited high-quality evidence. Early diagnosis and treatment were emphasized as critical factors in improving outcomes. Prophylactic antibiotics during stenting procedures and increased awareness among healthcare providers were suggested as preventive measures.

Isolated subdural hematoma due to dengue hemorrhagic fever: Surgical intervention and review of the literature.

Background: Central nervous system (CNS) complications of dengue fever, a mosquito-borne single standard RNA virus illness, are reported in <1% of all cases. Hemorrhagic complications in severe forms of the disease can be life-threatening. The literature on cases, where hemorrhagic CNS complications necessitated neurosurgical intervention, is exceedingly sparse. The authors report their experience of a patient who developed an isolated acute subdural hematoma (SDH) due to dengue hemorrhagic fever (DHF) in the critical period of the illness with a poor prognosis. Despite a moribund patient, the SDH was immediately evacuated, achieving a good outcome. Case Description: A 65-year-old male patient was admitted with high-grade febrile illness and diagnosed with dengue. The patient had no focal neurology and was managed adequately following the primary survey on admission but, then, developed severe thrombocytopenia and eventually the critical phase of dengue illness. On the 5th admission day, the patient collapsed. Glasgow Coma Score was 3/15 with bilaterally dilated, fixed pupils. Immediate computed tomography head revealed a large left SDH with a significant midline shift. SDH was emergently evacuated with two units of platelets transfused peroperatively and two additional units postoperatively. Thrombocytopenia resolved within 48 h, and interval scanning showed gradual resolution of SDH. The patient was discharged 18 days later. Five months later, on follow-up, the patient is well with mild left-sided weakness and an Extended Glasgow Outcome Score of 7. Conclusion: Isolated SDH is a rare but life-threatening hemorrhagic complication of DHF. Even in the critical phase of illness, with severe thrombocytopenia, surgical evacuation should be considered if the SDH is present in isolation, within an accessible area, and can be operated on immediately.