Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

Cost-effectiveness of craniotomy versus decompressive craniectomy for UK patients with traumatic acute subdural haematoma.

OBJECTIVE: To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH). DESIGN: Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial. SETTING: UK secondary care. PARTICIPANTS: 248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122). INTERVENTIONS: Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery). MAIN OUTCOME MEASURES: In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists. RESULTS: In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be -£5520 (95% CI -£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be -£4536 (95% CI -£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE. CONCLUSIONS: In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant). ETHICS: Ethical approval for the trial was obtained from the North West-Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076). TRIAL REGISTRATION NUMBER: ISRCTN87370545.

The Effect of Targeted Hyperoxemia on Brain Immunohistochemistry after Long-Term, Resuscitated Porcine Acute Subdural Hematoma and Hemorrhagic Shock.

Epidemiological data suggest that moderate hyperoxemia may be associated with an improved outcome after traumatic brain injury. In a prospective, randomized investigation of long-term, resuscitated acute subdural hematoma plus hemorrhagic shock (ASDH + HS) in 14 adult, human-sized pigs, targeted hyperoxemia (200 < PaO2 < 250 mmHg vs. normoxemia 80 < PaO2 < 120 mmHg) coincided with improved neurological function. Since brain perfusion, oxygenation and metabolism did not differ, this post hoc study analyzed the available material for the effects of targeted hyperoxemia on cerebral tissue markers of oxidative/nitrosative stress (nitrotyrosine expression), blood-brain barrier integrity (extravascular albumin accumulation) and fluid homeostasis (oxytocin, its receptor and the H2S-producing enzymes cystathionine-ß-synthase and cystathionine-γ-lyase). After 2 h of ASDH + HS (0.1 mL/kgBW autologous blood injected into the subdural space and passive removal of 30% of the blood volume), animals were resuscitated for up to 53 h by re-transfusion of shed blood, noradrenaline infusion to maintain cerebral perfusion pressure at baseline levels and hyper-/normoxemia during the first 24 h. Immediate postmortem, bi-hemispheric (i.e., blood-injected and contra-lateral) prefrontal cortex specimens from the base of the sulci underwent immunohistochemistry (% positive tissue staining) analysis of oxidative/nitrosative stress, blood-brain barrier integrity and fluid homeostasis. None of these tissue markers explained any differences in hyperoxemia-related neurological function. Likewise, hyperoxemia exerted no deleterious effects.

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma.

INTRODUCTION: The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH. MATERIALS AND METHODS: All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated. RESULTS: In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001). CONCLUSION: If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

Comparison of Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: A Systematic Review and Meta-Analysis.

OBJECTIVE: Acute subdural hematoma (ASDH) is a common critical neurosurgical condition, often requiring immediate surgical intervention. Craniotomy and decompressive craniectomy are the 2 mainstay surgical approaches. This comprehensive review and meta-analysis aims to summarize the existing evidence and compare the outcomes of these 2 procedures. METHODS: PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL electronic databases were searched for relevant studies, published between inception of databases till June 2023. Eligible studies reported data of patients diagnosed with ASDH who underwent craniotomy or decompressive craniectomy for ASDH. Outcome measures included the Glasgow Coma Scale score, residual subdural hematoma, requirement of revision surgery, poorer outcomes, and mortality. Data were presented as pooled odds ratios with 95% confidence intervals. Quality assessment and risk of bias were performed for each study. RESULTS: Fourteen studies with a total of 3095 patients were included. The results showed that patients who underwent craniotomy had significantly lower mortality, lower odds of poorer outcomes, and a higher rate of residual subdural hematoma, compared to patients who underwent decompressive craniectomy. There was no significant difference in the requirement of revision surgery between the 2 groups. Heterogeneity was high for most outcomes, and the quality of evidence ranged from moderate to low. CONCLUSION: Our findings suggest that craniotomy is associated with better clinical outcomes and lower mortality compared to decompressive craniectomy for ASDH, but a higher rate of residual subdural hematoma. Further high-quality randomized controlled trials are needed to validate our findings.

Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy.

OBJECTIVE: Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. MATERIALS AND METHODS: We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. RESULTS: We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). CONCLUSION: Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

Decompressive craniectomy versus craniotomy for acute subdural hematoma: Updated meta-analysis of real-world clinical outcome after RESCUE-ASDH trial.

INTRODUCTION: The Randomized Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation of Acute Subdural Hematoma trial found that disability and quality-of-life outcomes were similar between craniotomy and decompressive craniectomy for traumatic acute subdural hematoma (ASDH), contrasting previous literature. This meta-analysis aimed to validate the applicability of RESCUE-ASDH results using real-world data in ASDH patients. METHODS: We searched Chocrane, Embase, and MEDLINE for relevant articles reporting clinical outcomes of craniotomy and decompressive craniectomy. Meta-analysis used R software (Ross Ihaka and Robert Gentleman at the University of Auckland, New Zealand) with the restricted maximum likelihood method for random-effects meta-analyses, presenting odds ratios (ORs) and 95% confidence intervals (CIs) with Hartung-Knapp-Sidik-Jonkman adjustment for heterogeneity. RESULTS: Besides RESCUE-ASDH, five retrospective studies were included, spanning 2006 to 2016. A total of 961 patients with traumatic ASDH were included in this study (craniotomy, 467; decompressive craniotomy, 494). The pooled analysis of retrospective studies showed no significant difference in poor clinical outcomes between the two groups (OR, 0.59; 95% CI, 0.32-1.10). These findings align with the RESCUE-ASDH trial (OR, 0.84; 95% CI, 0.58-1.23). Mortality rate was significantly higher in patients undergoing craniectomy in pooled result of retrospective studies (OR, 0.59; 95% CI, 0.32-1.10). In RESCUE-ASDH trial, reoperation rate was higher in the craniotomy group, but the pooled result of retrospective did not show significant difference between the craniotomy and craniectomy group. CONCLUSION: This real-world evidence confirms the RESCUE-ASDH trial results. Both craniotomy and decompressive craniectomy yielded similar disability and quality-of-life outcomes for traumatic ASDH patients. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level III.

Actualización epidemiológica: tasa de mortalidad por Hemorragia Subdural Traumática entre los años 2018-2022 en Chile / Epidemiological update: traumatic Subdural Hemorrhage mortality rate between 2018-2022 in Chile

Traumatic subdural hemorrhage (TSH) is an injury between the meningeal membranes, caused by traumas, especially traffic accidents. OBJECTIVE: To describe the mortality rate (MR) due to TSH in the period 2018-2022 in Chile. MATERIALS AND METHODS: Descriptive, observational, and cross-sectional study on MR due to TSH in the period 2018-2022 in Chile, according to gender, age group, regional distribution, place of death, and month of death. Anonymous and public databases were used. No ethics committee approval was required. RESULTS: The average MR due to TSH in Chile from 2018 to 2022 was 0.45/100,000 inhabitants, with a peak in 2018 (0.75) and a minimum in 2021 (0.31). Men had higher rates. Mortality increased with age, especially in those over 80 years. The Metropolitan Region accounted for 35.2% of TSH-related deaths. Hospitals and clinics were the main places of death (67.1%), with more deaths in March, July, and August. DISCUSSION: The MR due to TSH progressively decreased due to medical improvements. Men have higher rates, possibly due to risk factors or biological differences. The reduction in MR in hospitals is linked to changes in the severity and categorization of the place of death. The connection with traffic accidents is significant, especially between March and August, due to the return to academic activities and weather conditions. Additionally, TSH-related deaths are concentrated in densely populated regions with more traffic accidents.

Rapid disappearance of acute subdural hematoma due to abrogated hyper-fibrinolytic activity by tranexamic acid: Case report.

RATIONALE: Acute subdural hematoma (ASDH) occurs after tearing of bridging veins within the dura resulting in the accumulation of blood between the arachnoid and dura layers within 72 hours after traumatic head injury. Also, antigen fibrin D-dimer (DD) is the principal enzymatic degradation product of cross-linked fibrin by plasmin. We observed that early tranexamic acid (TXA) treatment resolved hyper-fibrinolysis and rapid disappearance ASDH. PATIENTS CONCERNS: A 48-year-old female presented with unconsciousness for 2 hours after head trauma. Her Glasgow Coma Scale score was >8 points. DIAGNOSIS: Computed tomography scan established ASDH with midline shift and brainstem compression and surgery was scheduled. Also, laboratory results indicated high DD spike of 34,820 µg/L and a reduction in plasma fibrinogen 1 hour after the injury. INTERVENTION: She was treated with intravenous TXA immediately after admission. OUTCOMES: Her DD spike decreased remarkably in 48 hours with associated rapid disappearance of ASDH thereby averting surgical intervention. She recovered fully with no long-term complications. LESSONS: Historically, hyper-fibrinolysis is associated with poor outcome in head trauma. However, early initiation of TXA which is noninvasive treatment modality for ASDH could avert surgery and reduce cost, anesthesia, and other complications associated with surgery.

Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals.

BACKGROUND: Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients. METHODS: We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury. RESULTS: Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted). CONCLUSIONS: Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

Early Onset of Rapid Lesion Growth in an Acute Subdural Hematoma Model in Rats.

OBJECTIVE: Acute subdural hematoma (ASDH) leads to the highest mortality rates of all head injuries with secondary brain damage playing a pivotal role in terms of morbidity and mortality. In patients with ASDH, a delay in surgery leads to disproportional mortality. The benefit of (very) early therapy is therefore, a target of ongoing research. As the process of delayed brain damage in ASDH has not yet been described, this study therefore aimed to examine secondary lesion growth in an experimental rat model of ASDH to define the ideal timing for testing potential neuroprotective therapies. METHODS: Cerebral blood flow was monitored during ASDH induction with 300 µl of autologous blood. Lesion growth was characterized using Hematoxylin-Eosin- , Cresyl-Violet-, and Fluoro-Jade B-staining for early signs of neuronal degeneration. Histological evaluations were performed between 15 minutes and 24 hours after ASDH. RESULTS: There was a significant reduction of cerebral blood flow after ASDH. Fluoro-Jade B-positive cells were visible 15 minutes after ASDH in the lesioned hemisphere. Nonlinear growth of lesion volume from 3.7 ± 0.4 mm3 to 17.5 ± 0.6 mm3 was observed at 24 hours in Hematoxylin-Eosin-staining. CONCLUSIONS: The most damage develops between 15 minutes and 1 hour and again between 2 and 6 hours after ASDH. The time course of lesion growth supports the approach of early surgery for patients. It furthermore constitutes a basis for further ASDH research with more clearly defined time windows for therapy in animal models.

A revolutionary acute subdural hematoma detection based on two-tiered artificial intelligence model.

BACKGROUND: The article was planned to make the first evaluation in terms of acute subdural hemorrhages, thinking that it can help in appropriate pathologies by tomography interpretation with the artificial intelligence (AI) method, at least in a way to quickly warn the responsible doctor. METHODS: A two-level AI-based hybrid method was developed. The proposed model uses the mask-region convolutional neural network (Mask R-CNN) technique, which is a deep learning model, in the hemorrhagic region's mask generation stage, and a problem-specific, optimized support vector machines (SVM) technique which is a machine learning model in the binary classification stage. Furthermore, the bee colony algorithm was used for the optimization of SVM algorithms' parameters. RESULTS: In the first stage, the mean average precision (mAP) value was obtained as 0.754 when the intercept over union (IOU) value was taken as 0.5 with the Mask R-CNN architecture used. At the same time, when a 5-fold cross-validation was applied, the mAP value was obtained 0.736. With the hyperparameter optimization for both Mask R-CNN and the SVM algorithm, the accuracy of the two-level classification process was obtained as 96.36%. Furthermore, final false-negative rate and false-positive rate values were obtained as 6.20%, and 2.57%, respectively. CONCLUSION: With the proposed model, both the detection of hemorrhage and the presentation of the suspicious area to the physician were performed more successfully on two dimensional (2D) images with low cost and high accuracy compared to similar studies and today's interpretations with telemedicine techniques.

Is prophylactic anti-convulsive treatment necessary in subdural hematomas?

BACKGROUND: Subdural hematoma (SDH) is usually an emergent clinical condition in neurosurgery. The relationship between the SDH and epilepsy is not well established. Therefore, the use of anti-convulsive treatment in patients with SDH is controversial. The aim of this study is to analyze the presence of seizures in patients who underwent surgery for SDH. METHODS: Patients who were operated on for SDH in our department between 2016 and 2021 were reviewed retrospectively. Demographic features, Glasgow Coma Scale (GCS) score at admission, type of SDH, location, etiology, type of surgical intervention, presence of seizures, and re-operation were evaluated. RESULTS: There were 175 patients with SDH. There is a statistically significant difference between the frequency of seizures and the type of SDH. More seizures were observed in acute SDH than in the others. There is also a statistically significant difference between the GCS score and the frequency of seizures. Patients with a GCS score <12 at admission had more frequent seizures than patients with a score of 12 or higher. No statistically significant difference was found between factors such as etiology, re-operation, hematoma location, and the development of seizures. CONCLUSION: Anti-convulsive treatment may be recommended in patients with acute SDH and a low GCS score at admission. Further studies with larger series should be performed to determine the most appropriate anti-convulsive agent for patients with SDH.

Intracranial lesion features in moderate-to-severe traumatic brain injury: relation to neurointensive care variables and clinical outcome.

BACKGROUND: The primary aim was to determine the association of intracranial hemorrhage lesion type, size, mass effect, and evolution with the clinical course during neurointensive care and long-term outcome after traumatic brain injury (TBI). METHODS: In this observational, retrospective study, 385 TBI patients treated at the neurointensive care unit at Uppsala University Hospital, Sweden, were included. The lesion type, size, mass effect, and evolution (progression on the follow-up CT) were assessed and analyzed in relation to the percentage of secondary insults with intracranial pressure > 20 mmHg, cerebral perfusion pressure < 60 mmHg, and cerebral pressure autoregulatory status (PRx) and in relation to Glasgow Outcome Scale-Extended. RESULTS: A larger epidural hematoma (p < 0.05) and acute subdural hematoma (p < 0.001) volume, greater midline shift (p < 0.001), and compressed basal cisterns (p < 0.001) correlated with craniotomy surgery. In multiple regressions, presence of traumatic subarachnoid hemorrhage (p < 0.001) and intracranial hemorrhage progression on the follow-up CT (p < 0.01) were associated with more intracranial pressure-insults above 20 mmHg. In similar regressions, obliterated basal cisterns (p < 0.001) were independently associated with higher PRx. In a multiple regression, greater acute subdural hematoma (p < 0.05) and contusion (p < 0.05) volume, presence of traumatic subarachnoid hemorrhage (p < 0.01), and obliterated basal cisterns (p < 0.01) were independently associated with a lower rate of favorable outcome. CONCLUSIONS: The intracranial lesion type, size, mass effect, and evolution were associated with the clinical course, cerebral pathophysiology, and outcome following TBI. Future efforts should integrate such granular data into more sophisticated machine learning models to aid the clinician to better anticipate emerging secondary insults and to predict clinical outcome.

Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management.

BACKGROUND: The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH. OBJECTIVE: To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort. METHODS: We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically. RESULTS: We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome. CONCLUSION: MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.

BACKGROUND: Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. METHODS: We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS: A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group. CONCLUSIONS: Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).

Acute subdural haematoma exacerbates cerebral blood flow disorder and promotes the development of intraoperative brain bulge in patients with severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy (DC) is a routine procedure used for the treatment of severe traumatic brain injury (TBI) with concomitant acute subdural haematoma (SDH). However, certain patients are prone to developing malignant brain bulge during DC, which prolongs the operative time and worsens patient outcomes. Previous studies have shown that malignant intraoperative brain bulge (IOBB) may be associated with excessive arterial hyperaemia caused by cerebrovascular system disorders. Through a clinical retrospective analysis and prospective observations, we found that the cerebral blood flow of patients who possessed risk factors manifested high resistance and low flow velocity, which severely affected brain tissue perfusion and resulted in the occurrence of malignant IOBB. In the current literature, rat models of severe brain injury-associated brain bulge have rarely been reported. METHODS: To gain an in-depth understanding of cerebrovascular changes and the cascade of responses related to brain bulge, we introduced acute SDH into the Marmarou model for the preparation of a rat model of high intracranial pressure (ICP) to simulate the pathological conditions experienced by patients with severe brain injury. RESULTS: With the introduction of a 400-µL haematoma, significant dynamic changes occurred in ICP, mean arterial pressure, and relative blood perfusion rate of the cerebral cortical vessels. ICP increased to 56.9 ± 2.3 mmHg, mean arterial pressure showed reactive decrease, and the blood flow of cerebral cortical arteries and veins on the non-SDH-affected side decreased to < 10%. These changes could not fully recover even after DC. This resulted in generalised damage to the neurovascular unit and a lag effect to the venous blood reflux, which triggered malignant IOBB formation during DC. CONCLUSION: An excessive increase in ICP causes cerebrovascular dysfunction and brings about a cascade of damage to brain tissue, which forms the basis for the development of diffuse brain swelling. The subsequent heterogeneous responses of the cerebral arteries and veins during craniotomy may be the main cause of primary IOBB. Clinicians should pay particular attention to the redistribution of CBF to various vessels when performing DC in patients with severe TBI.

Supratentorial Acute Subdural Hematoma During Fully Endoscopic Microvascular Decompression Surgery for Hemifacial Spasm.

The endoscope has been widely used in microvascular decompression (MVD), which is the best curative treatment for hemifacial spasm. Supratentorial subdural hematoma (SDH) is rarely happened in MVD. The authors report 2 cases of SDH during full endoscopic MVD. The origin of bleeding is not confirmed during the operation. Rapid and excessive drainage of cerebrospinal fluid and the operation position may result the rupture of bridging veins, which result in the occurrence of SDH. However, there is no clear evidence to explain the clinical symptoms.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.