Assessment of Surgical Treatment and Outcome of Chronic Subdural Hematoma at University of Gondar Comprehensive Specialized Hospital, a one Year Prospective Study.

OBJECTIVE: Chronic subdural hematomas (CSDHs) are a relatively common condition defined as an abnormal collection of blood and its break down products in the subdural space, usually accompanied by a history of preceding mild head trauma. Surgical management remains the mainstay of treatment. The objective of this study was to assess the surgical treatment outcome of patients operated on for CSDH at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. This comprehensive novel study serves as a benchmark for assessing therapeutic outcomes among patients with CSDH in the context of Ethiopia. METHODS: Institution-based prospective observational study was conducted among patients operated on for symptomatic CSDH at University of Gondar Comprehensive Specialized Hospital from January 1, 2023, to December 31, 2023 G C. RESULT: A total of 107 patients (70 males (65.4%) and 37 females (34.6%) with a male to female ration of 1.9:1 and mean age of 62.4 and a standard deviation of 13.7 (range from 23 to 92) were studied. Fifyt-one (47.7%) of the patients had a history of antecedent trauma. In terms of clinical symptoms, 86 (80.4%) patients had weakness as the chief complaint, followed by headache in 81 (75.7%). Among complications, recurrence is the most common, which was seen in 16 (15%) patients, followed by altered mental status (confusion, delirium) in 18 (16.8%) patients. The mean duration of the hospital stay was 6 days, with a standard deviation of 4 days. The majority of the patients had a good recovery with the resumption of normal life: 92 (86%), 10 (9.3%) patients had moderate disability, were disabled but independent, 2 (1.8%) patients had severe disability, were dependent on daily support, and 3 (2.8%) patients died. CONCLUSION: CSDHs are a relatively common condition characterized by an abnormal collection of blood. Antecedent trauma is the usual risk factor. Complication can happen following surgical intervention; however, patients with CSDH generally have a good prognosis.

Quantitative Assessment of Brain Expansion After Evacuation of Chronic Subdural Hematoma as a Predictor of Recurrence.

BACKGROUND: A lack of brain expansion is considered a risk factor for recurrence after evacuation of a chronic subdural hematoma (CSDH). To the best of our knowledge, no studies have reported on objective measurement of brain expansion after evacuation of a CSDH. METHODS: We performed a retrospective analysis of prospectively collected data of patients undergoing 2 burr hole evacuation of a CSDH. We measured the depth of the brain surface from the frontal burr hole dural opening after hematoma evacuation using a specially devised measuring tool. Other predictors analyzed for recurrence of hematoma were age, gender, a history of hypertension, the use of anticoagulant and/or antiplatelet agents, Glasgow coma scale score at presentation, unilateral or bilateral hematoma, computed tomography appearance, and hematoma thickness. RESULTS: Among 88 patients who underwent hematoma evacuation, 3 (3.4%) underwent surgery for recurrence. The significant factors associated with recurrence were the presence of bilateral hematoma (P = 0.001), hematoma width >2.3 cm (P = 0.04), gradation type of hematoma on the computed tomography scan (P = 0.03), and the depth of the brain after hematoma evacuation (P = 0.02). The brain expanded less in those with recurrence, with a mean depth of the brain of 18 ± 6 mm versus 7.27 ± 7.8 mm in those without recurrence. CONCLUSIONS: Evacuation of a CSDH through 2 burr holes, along with copious irrigation and bed rest for 3 days, resulted in a very low recurrence rate without the use of a drain. A lack of brain expansion might be a predictor of recurrence. To the best of our knowledge, this is the first study to quantitatively measure the depth of the brain at surgery in patients undergoing surgery for CSDH.

Subdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas.

PURPOSE: We present a series that describes the presenting features and clinical outcomes in patients with CSDH treated with a standardised technique and an open-drain placement. METHODS: We reviewed the medical records of 155 consecutive patients at a single centre who underwent CSDH evacuation by placing burr holes, accompanied by intraoperative irrigation and a subdural Penrose drain between 2014 and 2018. RESULTS: The mean age was 65.9 years, 81.9% were males. The most common clinical characteristics were an altered mental state (21.9%) and headache (12.9%). It was necessary to perform a second surgical intervention due to the evidence in the postoperative tomography of a residual hematoma in 10.3% of the cases; there were 2 cases of recurrence in 6 months (1.3%). Pneumonia (6.5%) and seizures (5.8%) were the most frequent medical complications. Intracranial infections accounted for 1.9%, and the mortality rate was 6.4% of cases. CONCLUSIONS: We provided our experience with a low-cost and less-commonly used technique in the management of CSDH. This technique showed similar recurrence, mortality and intracranial infection rates to those reported in the literature for closed drainage systems. Additional studies will be required to assess this technique.

Cost Comparison for Open Surgery versus Middle Meningeal Artery Embolization in Patients with Chronic Subdural Hematomas: A Propensity Score-Matched Analysis.

BACKGROUND: Chronic subdural hematoma (cSDH) can be treated with conventional surgery or middle meningeal artery embolization (MMAE). The cost profiles of open surgery versus MMAE have never been studied. Therefore, we sought to compare the costs of surgical and MMAE treatment of cSDH. METHODS: Patients treated with open surgery (2006-2019) and MMAE (2018-2020) were identified from the institutional database. Propensity score matching analysis was used to assemble a balanced group of subjects. Detailed hospitalization costs in each group were collected and compared. RESULTS: A total of 341 conventionally treated and 52 MMAE cases were identified. After propensity score matching, 33 patients were included in each group, for a total of 66 patients for analysis. Direct procedural cost was significantly greater in the MMAE group compared with the open surgery group ($38,255 ± $11,859 vs. $11,206 ± $7888; P < 0.001). Medication cost also was greater in the MMAE group ($6888 ± $6525 vs. $4291 ± $3547; P = 0.048). No significant difference was found in costs for intensive care unit care, pharmacy, therapy, laboratory values, and the emergency department. Imaging costs and other miscellaneous costs (e.g., wound care, preoperative, and postanesthesia care unit) were greater in the open surgery group (P < 0.05). Total hospitalization cost was not significantly different between the 2 groups ($60,598 ± 61,315 vs. $71,569 ± $37,813 for open surgery and MMAE respectively, P = 0.385). No significant differences in number of follow ups or total costs for follow up were found (P > 0.05). CONCLUSIONS: Open surgery and MMAE offer an overall equivalent cost-profile for cSDH treatment when matching for potential cost confounders. Direct procedural costs are greater in MMAE; however, total hospitalization costs and follow up costs are not significantly different.

Swedish trial on embolization of middle meningeal artery versus surgical evacuation in chronic subdural hematoma (SWEMMA)-a national 12-month multi-center randomized controlled superiority trial with parallel group assignment, open treatment allocation and blinded clinical outcome assessment.

BACKGROUND: Chronic subdural hematoma (cSDH) is one of the most common neurosurgical disorders and the incidence is rising. The routine treatment is neurosurgical hematoma evacuation, which is associated with recurrence rates up to 10-25%. In recent years, endovascular embolization of the middle meningeal artery (eMMA) has garnered much attention due to recurrence rates as low as < 5%. Several randomized controlled trials are planned or ongoing. In most of these trials, conventional neurosurgical treatment with or without adjunctive endovascular embolization is compared. The proposed trial aims to conduct a head-to-head comparison between neurosurgical and endovascular treatment as stand-alone treatments. METHODS: The trial is academically driven and funded within existing public healthcare systems and infrastructure. Patients with uni- or bilateral cSDH, presenting with mild-to moderate symptoms, and admitted to neurosurgery on clinical grounds will be offered participation. Subjects are randomized 1:1 between conventional neurosurgical treatment (control) and endovascular embolization of the middle meningeal artery (intervention). Primary endpoint is reoperation due to clinically and/or radiologically significant recurrence within 3 months. Secondary endpoints include safety, technical success rate, neurological disability, and quality of life. DISCUSSION: There are mounting retrospective data suggesting eMMA, as sole treatment or as an adjunctive to neurosurgery for cSDH, is safe and effective with a reoperation rate lower than neurosurgical hematoma evacuation alone. If randomized controlled trials confirm these findings, there is a potential for a paradigm shift in the treatment of cSDH where a minimally invasive procedure can replace open surgery in a large and oftentimes old and fragile patient cohort. TRIAL REGISTRATION: ClinicalTrials.gov, ClinicalTrials.gov Identifier NCT05267184 . Registered March 4, 2022.

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 2-Burr Hole Craniostomy.

BACKGROUND: Nontraumatic subdural hematoma (SDH) is a common neurological disease that causes extensive morbidity and mortality. Craniotomy or burr hole craniostomy (BHC) is indicated for symptomatic lesions, but both are associated with high recurrence rates. Although extensive research exists on postoperative complications after BHCs, few studies have examined the underlying causes and predictors of unplanned 30-day hospital readmissions at the national level. OBJECTIVE: To compare causes for hospital readmission within 30 days after surgical SDH evacuation with BHC and evaluate readmission rates and independent predictors of readmission. METHODS: This retrospective cohort observational study was designed using the Nationwide Readmissions Database. We identified patients who had undergone BHC for SDH evacuation (2010-2015). National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS: We analyzed 2753 patients who had BHC for SDH evacuation: 675 (24.5%) had at least one 30-day readmission. Annual readmission rates did not vary across the study period ( P = .60). The most common cause of readmission was recurrent SDH (n = 630, 93.3%), and the next most common was postoperative infection (n = 12, 1.8%). Comorbidities significantly associated with readmission included fluid and electrolyte disorders, chronic blood loss anemia, chronic obstructive pulmonary disease, depression, liver disease, and psychosis ( P ≤ .04), but statistically significant independent predictors for readmission included only chronic obstructive pulmonary disease and fluid and electrolyte disorders ( P ≤ .007). CONCLUSION: These national trends in 30-day readmission rates after nontraumatic SDH evacuation by BHC not otherwise published provide quality benchmarks that can aid national quality improvement efforts.

Inversed probability case-control analysis of operative burr hole evacuation versus subdural evacuating port system for chronic subdural hematomas: Clinical and economic outcomes.

INTRODUCTION: There are multiple treatments for a chronic subdural hematoma, a significant cause of neurosurgical morbidity that cost the healthcare system $5B in 2007, but few generalizable prospective studies. The purpose of this study was to examine outcomes of bedside Subdural Evacuation Port System (SEPS) placement as compared to operating room burr hole evacuation (BHE) to acquire data to support a randomized trial. METHODS: All procedures were performed in a single institution between 2011 and 2019. Patients were included if > 18 years of age, had chronic subdural hematoma, and were treated by SEPS or BHE. Patients with prior neurosurgical history, mass lesions or bilateral hematomas were excluded. Patients who met inclusion for SEPS (n = 55) or BHE (n = 105). Samples were propensity matched to account for variability. Non-inferiority tests compared outcomes. Cost data was obtained through billable charges. RESULTS: Patients with multiple comorbidities were more likely to undergo SEPS drainage. Noninferiority tests reported no statistically significant evidence to suggest SEPS drains were worse in reoperation-rate (18% vs 9%), post-operative seizure, or functional outcome. SEPS drain placement trended towards a faster time to procedure (3 h faster; p = 0.07) but the overall hospital stay was longer (4.23 vs 5.81, p = 0.01). SEPS drain placement costs are less than BHE, but these patients had 25% higher overall hospital costs (p = 0.01) due to comorbidities and increased hospital stay.

Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis.

BACKGROUND: Middle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH. METHODS: Data for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments. RESULTS: Of 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference -$32 776; 95% CI -$52 766 to -$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001). CONCLUSIONS: MMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions.

Predicting for Lost to Follow-up in Surgical Management of Patients with Chronic Subdural Hematoma.

BACKGROUND: Lost to follow-up (LTF) represents an understudied barrier to effective management of chronic subdural hematoma (cSDH). Understanding the factors associated with LTF after surgical treatment of cSDH could uncover pathways for quality improvement efforts and modify discharge planning. We sought to identify the demographic and clinical factors associated with patient LTF. METHODS: A single-institution, retrospective cohort study of patients treated surgically for convexity cSDH from 2009 to 2019 was conducted. The primary outcome was LTF, with neurosurgical readmission as the secondary outcome. Univariate analysis was conducted using the student-t test and χ2 test. Multivariate logistic regression was performed to identify the factors associated with LTF and neurosurgical readmission. RESULTS: A total of 139 patients were included, 29% of whom were LTF. The mean first postoperative follow-up duration was 60 days. On univariate analysis, uninsured/Medicaid coverage was associated with increased LTF compared with private insurance/Medicare coverage (62.5% vs. 41.4%; P = 0.039). A higher discharge modified Rankin scale score was also associated with LTF (3.7 vs. 3.5; P < 0.001). On multivariate analysis, uninsured/Medicaid patients had a significantly greater risk of LTF compared with private insurance/Medicare patients (odds ratio, 2.44; 95% confidence interval, 1.13-5.23; P = 0.022). LTF was independently associated with an increased risk of neurosurgical readmission (odds ratio, 1.94; 95% confidence interval, 1.17-3.24; P = 0.011). CONCLUSIONS: Uninsured and Medicaid patients had a greater likelihood of LTF compared with private insurance and Medicare patients. LTF was further associated with an increased risk of neurosurgical readmission. The results from the present study emphasize the need to address barriers to follow-up to reduce readmission after surgery for cSDH. These findings could inform improved discharge planning, such as predischarge repeat imaging studies and postdischarge contact.

Assessment of Frailty in Predicting Surgical Outcomes in Patients with Chronic Subdural Hematomas: Retrospective Chart Review.

BACKGROUND: The aim of this study is to determine if frailty, defined as modified frailty index (MFI) >2.7, correlated with worse postoperative outcomes in patients with chronic subdural hematomas (CSDHs). We also compare the predictive ability of the MFI with another widely used frailty measure, the Clinical Frailty Scale (CFS). METHODS: We conducted a retrospective chart review of elderly patients (≥65 years) who underwent a twist-drill craniostomy for the evacuation of CSDH at Hamilton General Hospital, Canada, between 2016 and 2018. The primary outcome was the modified Rankin Scale scores at discharge. Logistic regression analyses and receiver operating characteristic curves were carried out to further analyze the factors that influenced independence and functional improvement at discharge. RESULTS: Frail patients were significantly more dependent at discharge (P < 0.0001) and had a lower rate of functional improvement (P = 0.003). When compared with frailty measured by the MFI, frailty as measured by the CFS had a stronger association with functional independence (odds ratio [OR]: 0.081 [0.031, 0.211] vs. OR: 0.256 [0.124, 0.529]) and functional improvement (OR: 0.272 [0.106, 0.693] vs. OR: 0.406 [0.185,0.889]) on logistic regression analyses. Area under the receiver operating characteristic curve analyses showed that the inclusion of frailty into our predictive models improved accuracy. CONCLUSIONS: Elderly patients presenting with CSDH who are frail (MFI >0.27) have significantly worse functional outcomes following twist-drill craniostomies. Therefore assessing frailty in this population is important before managing these patients, and for this purpose the CFS is a superior predictor of postoperative function than the MFI.

Trial of Dexamethasone for Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied. METHODS: We conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death). RESULTS: From August 2015 through November 2019, a total of 748 patients were included in the trial after randomization - 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, -6.4 percentage points [95% confidence interval, -11.4 to -1.4] in favor of the placebo group; P = 0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group. CONCLUSIONS: Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.).

Risk-assessment in chronic subdural hematoma evaluated in 148 patients - A score for predicting recurrence.

BACKGROUND: Chronic subdural hematoma (CSDH) is a frequent disease in neurosurgical practice. However, a considerable recurrence rate keeps this condition challenging to treat. We aimed to provide a simple tool for risk assessment in these patients. METHODS: We conducted a retrospective analysis of surgically treated patients with chronic subdural hematomas. In addition to patients' demographics, radiological assessment included volume, thickness, midline shift and density of hematomas. Statistically significant variables in univariate analysis were further analyzed in a multivariate logistic regression model to create a risk score for recurrence of CSDH. RESULTS: A total of 148 patients were identified and included for analysis. 50.7 % (n = 75) were older than 76 years of age. The overall hematoma recurrence rate requiring surgery was 23.6 % (n = 35). Preoperative thrombocytopenia, postoperative midline shift >6 mm, hematoma volume >80 mL and overall hematoma density >45 Hounsfield Units (HU), were significantly more frequent in the recurrence group. Furthermore, after multivariate assessment, postoperative hematoma density and volume were independent risk factors and included in the risk assessment tool. Patients were divided into 3 risk groups corresponding to the total scores. CONCLUSION: We provide a risk-score assessment for predicting recurrence of subdural hematoma. The risk-score comprises postoperative hematoma volume and density. This tool could ease decision making in follow-up evaluation and indication for recurrence surgery. Yet, further prospective evaluation is required to assess the clinical value of this tool.

Chronic subdural hematoma-incidence, complications, and financial impact.

OBJECTIVE: To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT). METHODS: A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland). RESULTS: The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia. CONCLUSIONS: Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

Intraoperative point-of-care assessment of an inflammatory biomarker in chronic subdural hematomas: Technical note.

OBJECTIVE: Inflammatory processes have been associated with the development and recurrence of chronic subdural hematomas (cSDH). Elevated levels of presepsin, a truncated N-terminal fragment of soluble CD14, occur in various inflammatory conditions of bacterial and non-bacterial origin. Here we report on our initial experiences with the intraoperative point-of-care (POC) assessment of presepsin in patients treated for cSDH. PATIENTS AND METHODS: The POC analyser Pathfast® was used in 21 patients treated for cSDH at our institution. Prior to surgery, levels of C-reactive protein (CRP) and white blood cells (WBC) were assessed. After burr hole trephination and dura incision, samples of subdural fluid and whole blood were collected and immediately assessed with the POC analyser. Values of presepin were compared between samples of the subdural compartment and whole blood. RESULTS: Presepsin levels were assessed within 13 min in all patients and no technical difficulties occurred. Compared to the reported normal range values of presepsin (55-184 pg/mL), mean levels of presepsin in samples of the subdural compartiment was increased more than 5-fold (821 ±â€¯110.1 pg/mL). Furthermore, mean presepsin values in samples of the subdural compartiment were significantly higher than in samples of whole blood (154.8 ±â€¯19.2 pg/mL; p < 0.0001). CONCLUSION: POC assessment of the inflammatory biomarker presepsin is feasible within minutes during surgical treatment of cSDH. Corresponding to previous studies, presepsin levels were highly elevated in the subdural fluid, indicating processes of inflammation. Whether results of intraoperative POC assessment of inflammatory biomarkers is associated with outcome parameters in patients treated for cSDH has to be addressed in further studies. In our view, there is a role for this promising technique in improving future treatment strategies in respective patients.

Epidemiology and Estimated Cost of Surgery for Chronic Subdural Hematoma Conducted by the Unified Health System in Brazil (2008­2016)

Introduction Chronic subdural hematoma (CSH) is one of the most frequent forms of intracranial hemorrhage. It is a collection of encapsulated, well-delimited fluid and/or coagulated blood in several clotting stages located between the dura mater and the arachnoid mater. Objective To describe the epidemiological aspects of CSH described in the database of the Brazilian Unified Health System (SUS, in the Portuguese acronym) regarding admission numbers, hospitalization expenses, health care professional expenses, mortality rate, and death numbers by region from 2008 to the first half of 2016. Methods The present work was performed between August and September 2016 with a review about the epidemiological aspects of CSH in Brazil according to the Informatics Department of the Unified Health System (DATASUS) database, encompassing the period from January 2008 to June 2016, and to scientific papers from the past 10 years which were electronically published at the PubMed, Scielo, and LILACS databases. Results From 2008 to the first half of 2016, the total values were the following: hospital admission authorizations (HAAs). 33,878; hospital expenses, BRL 65,909,429.22; health care professional expenses, BRL 25,158,683.21; deaths, 2,758; and mortality rates ranging from 6.47 to 12.63%. Conclusion In spite of the high clinical relevance of CSH, epidemiological studies about this condition are limited. As such, the present paper is an updated approach on CSH, focusing on its epidemiological aspects according to the DATASUS database.

Standardized assessment of outcome and complications in chronic subdural hematoma: results from a large case series.

INTRODUCTION: Chronic subdural hematomas (cSDH) are commonly deemed to have a benign prognosis. However, detailed and standardized data describing outcome and complications in a large prospective patient cohort is lacking. METHODS: Retrospective analysis of prospectively collected data in our institutional patient registry on consecutive patients undergoing surgery for cSDH from 2013 to 2017. Complications were assessed according to the Clavien-Dindo grading system (CDG). The outcome was measured with respect to two endpoints: occurrence of a complication with CDG 3-5 and lack of improvement in Karnofsky Performance Status (KPS) at the last follow-up. RESULTS: Out of 435 operations, 166 (38.3%) presented a complication until 3 months postoperative (CDG 1, 23 (5.3%); CDG 2, 62 (14.3%); CDG 3a, 7 (1.6%); CDG 3b, 64 (14.7%); CDG 4a, 2 (0.5%); and CDG 5, 8 (1.8%)). Higher CDG correlated with a lower KPS (rs = - 0.27, p < 0.001). A lack of improvement in KPS was associated with a Charlson Comorbidity Index (CCI) > 1 and the iso- or hypodense appearance of the cSDH. CONCLUSIONS: This study provides a reliable estimate of the rate of medical and surgical complications in cSDH surgery. Complications that required a surgical intervention turned out to be rare. Recording complications in a standardized and prospective fashion can therefore serve as a basis for assessing patient outcome and quality control within the department.

Surgical Drains in Chronic Subdural Hematoma Surgery: From the Cheapest to the Most Expensive Drains.

OBJECTIVE: Among the various neurosurgical techniques currently being used in chronic subdural hematoma (CSDH) surgery, bur hole craniostomy is the most popular worldwide. Recent studies have strongly recommended that a drain be placed after surgical evacuation of a hematoma, and a broad spectrum of preformed surgical drains is widely available for this purpose. If preformed drains are unavailable, a surgeon-made drain can be used and various methods are available to develop a drain in the operating room. METHODS: Using a case report, we demonstrate how to develop a surgeon-made drain. Next, we retrospectively screened for subdural drain usage in consecutive patients undergoing bur hole drainage for CSDH at Adiyaman University Hospital between January 2017 and April 2017, and data from only those patients in whom a surgeon-made drain was used were included for analyses. RESULTS: A 74-year-old male was operated with the diagnosis of CSDH. Assembly of a surgeon-made drain was explained step by step. Our review identified 6 unilateral and 2 bilateral cases in which 10 surgeon-made drains were used. Mean age of the patients was 72, and mean follow-up period was 7 months, 23 days. No instances of infection or drain-related complications had been recorded. The recurrence rate was 0%, and the average drainage period was 3.4 days. CONCLUSIONS: In case of unavailability of a preformed drain, a surgeon-made drain can be used during CSDH surgery. Different methods are available and can be further diversified using various combinations of simple medical materials.

Mini-Craniotomy Under Local Anesthesia for Chronic Subdural Hematoma: An Effective Choice for Elderly Patients and for Patients in a Resource-Strained Environment.

BACKGROUND: Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA). MATERIALS AND METHODS: This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged 55 years or older undergoing surgery for CSDH. Clinical characteristics, hospital stay, and recurrence rates were compared between 2 groups, local versus general anesthesia. RESULTS: Thirty-five patients underwent mini-craniotomy for CSDH in the study period. Sixteen patients underwent mini-craniotomy under LA versus 19 patients for GA. Median age for the LA group was 67 years compared with 70 years in the GA group. Four patients from the LA group experienced postoperative complications versus 7 from the GA group. Only one patient in the LA group required an ICU bed in the postoperative period. There was no recurrence in LA group. The overall recurrence was 2.86%. CONCLUSIONS: Mini-craniotomy for CSDH under LA is an equally effective procedure compared with mini-craniotomy under GA. In addition, it minimizes the risks of GA in the elderly population and obviates the need of a postoperative ICU bed. It also reduces operative time and hospital stay as compared with GA.

Quantitative assessment of brain shifting in the late phase postevacuation in unilateral and bilateral chronic subdural hematomas.

AIM OF THE STUDY: Recurrence is more common in bilateral chronic subdural hematomas (CSDHs) than in unilateral. Our aim was to quantitatively compare the late phase of brain shifting postevacuation in unilateral and bilateral CSDHs. MATERIALS AND METHODS: We reviewed computed tomography (CT) scans and medical records of consecutive patients with CSDHs who underwent burr hole drainage. CT scan images (preoperative and postoperative days [PODs] 30 and 60) were imported to Adobe Photoshop, and temporal and spatial changes in brain shifting between PODs 30 and 60, and also the subdural space on POD 60, were analyzed. RESULTS: The bilateral group exhibited a significantly greater late phase of brain shifting than the unilateral group between PODs 30 and 60 (P < 0.001). The median late phase of brain shifting of the bilateral group was 8.9 mm (interquartile range [IQR]: 8.3-9.0 mm) between PODs 30 and 60, while that of the unilateral group was 1.8 mm (IQR: 1.3-2.5 mm). CONCLUSIONS: The postevacuation late phase of brain shifting is statistically greater in bilateral CSDHs than in unilateral CSDHs, which might facilitate bridging vein tearing and consequent rebleeding. This may be one factor accounting for the higher recurrence rate of bilateral CSDHs.