Recurrence of chronic subdural hematoma due to low-grade infection.

Despite the high incidence and multitudes of operative techniques, the risk factors for chronic subdural hematoma (CSDH) recurrence are still under debate and a universal consensus on the pathophysiology is lacking. We hypothesized that clinically inapparent, a low-grade infection could be responsible for CSDH recurrence. This investigation is a single-center prospective observational study including patients with recurrent CSDH. In total, 44 patients with CSDH recurrence received an intraoperative swab-based microbiological test. The intraoperative swab revealed an inapparent low-grade hematoma infection in 29% of the recurrent CSDH cases. The majority (69%) of the identified germs belonged to the staphylococcus genus. We therefore, propose a novel potential pathophysiology for CSDH recurrence.

Subdural Pneumocephalus Aspiration Reduces Recurrence of Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, with symptoms ranging from headaches to coma. Operative evacuation is the treatment of choice. Subdural reaccumulation leading to reoperation is a vexing postoperative complication. OBJECTIVE: To present a novel technique for intraoperative aspiration of pneumocephalus via a subdural drain following SDH evacuation as a method of reducing potential subdural space and promoting cerebral expansion, thereby decreasing SDH recurrence. METHODS: In this retrospective study, 15 patients who underwent operative evacuation of cSDH between 2008 and 2015 were assessed. Six patients underwent a small craniotomy with intraoperative pneumocephalus aspiration. These patients were matched by age, gender, and anticoagulation status to 9 patients who underwent evacuation of SDH without pneumocephalus aspiration. Quantitative volumetric analysis was performed on the preoperative, postoperative, and 1-mo follow-up computed tomography scan to assess the subdural volume. RESULTS: In the immediate postoperative period, there was no difference in the percentage of residual subdural fluid between the aspiration and control groups (0.291 vs 0.251; P = 1.00). There was a decrease in amount of pneumocephalus present when the aspiration technique was applied (0.182 vs 0.386; P = .041). At 1-mo follow-up, there was a decrease in the residual cSDH volume between the aspiration and the control groups (28.7 mL vs 60.8 mL; P = .011). The long-term evacuation rate was greater in the aspiration group (75.4% vs 51.6%; P = .015). CONCLUSION: Intraoperative aspiration of cSDH cavity is a safe technique that may enhance cerebral expansion and reduce likelihood of cSDH recurrence.

Transcranial color-coded duplex sonography for evaluation of midline-shift after chronic-subdural hematoma evacuation (TEMASE): A prospective study.

OBJECTIVE: The incidence of chronic Subdural hematoma (cSDH) is increasing and its rate of recurrence varies from 5 to 33%. A postoperative brain midline-shift (MLS) on computed tomography (CT) equal or larger than 5mm is a risk factor for recurrence. Transcranial color-coded duplex sonography (TCCDS) is a noninvasive bedside reproducible technique useful to detect MLS. The aim of our study was to compare in patients affected by cSDH, the values of MLS obtained pre- and post-operatively by TCCDS and brain CT. PATIENTS AND METHODS: 32 patients affected by cSDH entered the study between July 2016 and January 2017. MLS values obtained by TCCDS and brain CT were compared using Bland-Altman plot and linear regression analysis. Using the same techniques we also explored if the agreement between the two imaging modes was comparable in pre- and post-operative data pairs. RESULTS: 64 data pairs of MLS values obtained by TCCDS and CT were analysed. Bland-Altman diagrams did not show any systematic bias of the data and linear regression indicated a significant correlation between the two measures both before and after hematoma evacuation. CONCLUSION: In patients affected by cSDH, MLS values obtained before and after surgery by TCCDS are comparable to those obtained by CT; TCCDS might be considered an alternative to CT scan in the management of patients after cSDH evacuation. We suggest that close clinical bedside examination and TCCDS might be appropriate for the post-operative management of cSDH, reserving CT scan only to patients with overt clinical deterioration and/or increasing MLS.