Challenges and patient outcomes in chronic subdural haematoma at the level of a regional care system A multi-centre, mixed-methods study from the East of England.

BACKGROUND: Chronic subdural haematoma (cSDH) is a common neurosurgical pathology affecting older patients with other health conditions. A significant proportion (up-to 90%) of referrals for surgery in neurosciences units (NSU) come from secondary care. However, the organisation of this care and the experience of patients repatriated to non-specialist centres are currently unclear. OBJECTIVES: This study aimed to clarify patient outcome in non-specialist centres following NSU discharge for cSDH surgery and to understand key system challenges. The study was set within a representative neurosurgical care system in the east of England. DESIGN AND METHODS: We performed a retrospective cohort analysis of patients referred for cSDH surgery. Alongside case record review, patient and staff experience were explored using surveys as well as an interactive c-design workshop. Challenges were identified from thematic analysis of survey responses and triangulated by focussed workshop discussions. RESULTS: Data on 381 patients referred for cSDH surgery from six centres was reviewed. One hundred and fifty-six (41%) patients were repatriated following surgery. Sixty-one (39%) of those repatriated suffered an inpatient complication (new infection, troponin rise or renal injury) following NSU discharge, with 58 requiring institutional discharge or new care. Surveys for staff (n = 42) and patients (n = 209) identified that resourcing, communication, and inter-hospital distance posed care challenges. This was corroborated through workshop discussions with stakeholders from two institutions. CONCLUSIONS: A significant amount of perioperative care for cSDH is delivered outside of specialist centres. Future improvement initiatives must recognise the system-wide nature of delivery and the challenges such an arrangement presents.

Passive or active drainage system for chronic subdural haematoma-a single-center retrospective follow-up study.

BACKGROUND: Postoperative drainage systems have become a standard treatment for chronic subdural hematoma (CSDH). We previously compared treatment results from three Scandinavian centers using three different postoperative drainage systems and concluded that the active subgaleal drainage was associated with lower recurrence and complication rates than the passive subdural drainage. We consequently changed clinical practice from using the passive subdural drainage to the active subgaleal drainage. OBJECTIVE: The aim of the present study was to assess a potential change in reoperation rates for CSDH after conversion to the active subgaleal drainage. METHODS: This single-center cohort study compared the reoperation rates for recurrent same-sided CSDH and postoperative complication rates between patients treated during two study periods (passive subdural drainage cohort versus active subgaleal drainage cohort). RESULTS: In total, 594 patients were included in the study. We found no significant difference in reoperation rates between the passive subdural drain group and the active subgaleal drain group (21.6%, 95% CI 17.5-26.4% vs. 18.0%, 95% CI 13.8-23.2%; p = 0.275). There was no statistical difference in the rate of serious complications between the groups. The operating time was significantly shorter for patients operated with the active subgaleal drain than patients with the passive subdural drain (32.8 min, 95% CI 31.2-34.5 min vs. 47.6 min, 95% CI 44.7-50.4 min; p < 0.001). CONCLUSIONS: Conversion from the passive subdural to the active subgaleal drainage did not result in a clear reduction of reoperation rates for CSDH in our center.

Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis.

A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.

How does research activity align with research need in chronic subdural haematoma: a gap analysis of systematic reviews with end-user selected knowledge gaps.

BACKGROUND: Chronic subdural haematoma (CSDH) is increasingly common. Although treatment is triaged and provided by neurosurgery, the role of non-operative care, alongside observed peri-operative morbidity and patient complexity, suggests that optimum care requires a multi-disciplinary approach. A UK consortium (Improving Care in Elderly Neurosurgery Initiative [ICENI]) has been formed to develop the first comprehensive clinical practice guideline. This starts by identifying critical questions to ask of the literature. The aim of this review was to consider whether existing systematic reviews had suitably addressed these questions. METHODS: Critical research questions to inform CSDH care were identified using multi-stakeholder workshops, including patient and public representation. A CSDH umbrella review of full-text systematic reviews and meta-analysis was conducted in accordance with the PRISMA statement (CRD42022328562). Four databases were searched from inception up to 30 April 2022. Review quality was assessed using AMSTAR-2 criteria, mapped to critical research questions. RESULTS: Forty-four critical research questions were identified, across 12 themes. Seventy-three articles were included in the umbrella review, comprising 206,369 patients. Most reviews (86.3%, n=63) assessed complications and recurrence after surgery. ICENI themes were not addressed in current literature, and duplication of reviews was common (54.8%, n=40). AMSTAR-2 confidence rating was high in 7 (9.6%) reviews, moderate in 8 (11.0%), low in 10 (13.7%) and critically low in 48 (65.8%). CONCLUSIONS: The ICENI themes have yet to be examined in existing secondary CSDH literature, and a series of new reviews is now required to address these questions for a clinical practice guideline. There is a need to broaden and redirect research efforts to meet the organisation of services and clinical needs of individual patients.

Assessing the accuracy of the International Classification of Disease (ICD) framework in the identification of patients with chronic subdural haematoma from hospital records.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the commonest neurosurgical pathologies with an increasing incidence. Observational studies of routine care have demonstrated high perioperative morbidity and approximately 10% mortality at one year. The development, implementation, and evaluation of a potential care framework relies on an accurate and reproducible method of case identification and case ascertainment. With this manuscript, we report on the accuracy of diagnostic ICD codes for identifying patients with CSDH from retrospective electronic data and explore whether basic demographic data could improve the identification of CSDH. METHODS: Data were collected retrospectively from the hospital administrative system between 2014 and 2018 of all patients coded with either S065 or I620. Analysis of the ICD codes in identifying patients with CSDH diagnosis was calculated using the caretR package in RStudioR,.and stepwise logistic regression analysis was performed to evaluate the best predictive model for CSDH. RESULTS: A total of 1861 patients were identified. Of these, 189 (10.2%) had a diagnosis of non-traumatic SDH (I620) and 1672 (89.8%) traumatic subdural haematomas (S065). Variables that identified CSDH as a diagnosis on univariate logistic regression included male sex (Odds Ratios (OR) - 1.606 (1.197-2.161), elderly age (OR) - 1.023 (1.015-1.032) per year for age (p < 0.001) and shorter length of hospital stay. Using stepwise regression against AIC the best model to predict CSDH included male sex, older age, and shorter LOS. The calculated sensitivity for identifying CSDH with the model is 88.4% with a specificity of 84.5% and PPV of 87.9%. CONCLUSION: CSDH is a common neurosurgical pathology with increasing incidence and ongoing unmet clinical need. We demonstrate that case ascertainment for research purposes can be improved with the incorporation of additional demographic data but at the expense of significant case exclusion.

Time to medical fitness for discharge following surgical evacuation of chronic subdural haematoma with general or regional anaesthesia: a prospective randomised trial.

General or regional anaesthesia can be used for chronic subdural haematoma evacuation, but no study has compared these types of anaesthesia in terms of peri-operative outcomes. This single-centre, prospective, randomised study included adult patients (age ≥ 18 years) undergoing surgical chronic subdural haematoma evacuation. Patients were randomly allocated to general (target-controlled total intravenous anaesthesia with propofol and remifentanil) or regional anaesthesia (bilateral scalp block with remifentanil sedation if required). The primary outcome measure was duration of hospital stay, based on the day patients were judged by an investigator blinded from the allocation group to be medically fit for discharge. Secondary outcomes included: rate of regional anaesthesia failure; rate of intra-operative and postoperative adverse events at 24 hours; and pain scores at 24 hours. Data from 60 patients were analysed (30 general anaesthesia and 30 regional anaesthesia). Median (IQR [range]) time until patients were judged medically fit for discharge was 3 (3-3 [2-10]) days and 3 (2-5 [2-15]) days for general and regional anaesthesia, respectively (p = 0.700). Regional anaesthesia failed in two patients. There were more intra-operative adverse events in patients who received general anaesthesia (25 vs. 11, respectively; p = 0.001). The occurrence of postoperative adverse events was similar for general and regional anaesthesia (16 vs. 13 patients, respectively; p = 0.605). In patients requiring chronic subdural haematoma evacuation, general and regional anaesthesia are comparable in terms of duration of time until medically fit for discharge and occurrence of postoperative complications. The rate of intra-operative adverse events (mainly arterial hypotension) is greater with general anaesthesia.

Chronic subdural haematoma: the role of peri-operative medicine in a common form of reversible brain injury.

Epidemiological studies project a significant rise in cases of chronic subdural haematoma over the next 20 years. Patients with this condition are frequently older and medically complex, with baseline characteristics that may increase peri-operative risk. The intra-operative period is only a small portion of a patient's total hospital stay, with a majority of patients in the United Kingdom transferred between institutions for their surgical and rehabilitative care. Definitive management remains surgical, but peri-operative challenges exist which resonate with other surgical cohorts where multidisciplinary working has become the gold standard. These include shared decision-making, medical optimisation, the management of peri-operative anticoagulation and the identification of key points of equipoise for examination in the future trials. In this narrative review, we use a stereotyped patient journey to provide context to the recent literature, highlighting where multidisciplinary expertise may be required to optimise patient care and maximise the benefits of surgical management. We discuss the triage, pre-operative optimisation, intra-operative management and immediate postoperative care of patients undergoing surgery for a chronic subdural haematoma. We also discuss where adjunctive medical management may be indicated. In so doing, we present the current and emerging evidence base for the role of an integrated peri-operative medicine team in the care of patients with a chronic subdural haematoma.

Risk factors for postoperative seizures in patients with chronic subdural haematomas.

Postoperative seizures are a frequently occurring yet not well-understood complication in patients undergoing surgical treatment of chronic subdural haematomas (cSDHs). Therefore, we investigated surgical and non-surgical risk factors that are commonly considered causal in provoking epileptic seizures, paying special attention to the intracranial course of the subdural drain (SDD) and the configuration of the haematoma. Data of patients with a cSDH, that were treated at our neurosurgical department between 2008 and 2014 were analysed. Patients suffering from severe pre-existing conditions and those who have been treated conservatively were excluded. Epidemiologic data as well as relevant clinical data were collected. Pre- and postoperative CT scans were analysed regarding morpho- and volumetric parameters. In order to objectify the influence of the SDD, its intracranial course and localisation (entering angle as well as the angle between drain and brain surface) were measured. For statistical analysis, univariate and multiple logistic regression models as well as Fisher's exact test were used. Two hundred eleven consecutive patients have been included. Mean age was 75.6 years, and 69% were male. Nineteen (9%) patients suffered from postsurgical seizures. Membranes within the haematoma were present in 81.5%. Pre- to postoperative haematoma reduction was significant (mean of difference - 12.76 mm/ - 9.47 mm in coronal/axial CT planes, p = 0.001/ < 0.001). In 77.9%, SDD showed cortical contact with eloquent regions and had an unfavourable course in 30 cases (14.2%). Surgical complications consisted of cortical bleeding in 2.5%, fresh subdural haematoma in 33.5% and wound infections in 1.4% of patients. Neither in univariate nor in multiple regression analyses any of the following independent variates was significantly correlated with postsurgical seizures: pre-existing epilepsy, alcohol abuse, right-sided haematomas, localization and thickness of haematoma, presence of septations, SDD-localization and to-brain angle, subdural air, and electrolyte levels. Instead, in multiple regression analyses, we found the risk of postsurgical seizures to be significantly correlated and increased with left-sided cSDH treated via craniotomy (p = 0.03) and an unfavourable course of the SDD in left-sided cSDH (p = 0.033). Burr hole trepanation should be preferred over craniotomy and care must be taken when placing a SDD to avoid irritating cortical tissue. The configuration of the haematoma does not appear to affect the postoperative seizure rate.

Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study.

Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.

Domestic violence in the clinical practice of gynecologists and obstetricians.

The issue of domestic violence is neglected in current medical practice and the dia-gnosis associated with it thus escapes the attention of medical professionals. In this case report, we demonstrate rare and typical diseases of abused women, which should become warning signs for physicians (red flags) and lead them to screen domestic violence and intervene early. Failure to recognize domestic abuse as the cause of chronic health problems leads to lasting consequences and economically and personally burdens the health care system. Healthcare professionals of all specialties encounter abused women during their clinical practice and can thus actively participate in the prevention of domestic violence. However, it is women of reproductive age who are most at risk, so educating gynecologists and obstetricians on this issue is crucial. The aim of this article with a case study is to demonstrate the syndrome of a battered woman, its recognition and the possibility of immediate and brief intervention.

Evaluating the optimal number of burr-holes for treating chronic subdural haematomas: good results from a single burr-hole?

INTRODUCTION: Chronic subdural haematomas (cSDH) are one of the most common types of traumatic intracranial lesion. Burr-hole craniostomy followed by closed-system drainage has become the treatment of choice. However, there is no definitive indication as to the number of burr-holes needed. Our aim was to to assess clinical and radiological outcomes taking into account the number of burr-holes made. MATERIAL AND METHODS: A retrospective single-centre-study was performed including patients treated for cSDH by performing burr-hole craniostomy from 2012 to 2018. After collecting data regarding demographics, comorbidities, and clinical and radiological records, haematomas were grouped depending on the number of burr-holes made (Group 1: single burr-hole; Group 2: double burr-holes). Clinical and radiological outcomes were statistically compared between groups, as well as the main complications. RESULTS: After collecting 171 patients, 205 cSDHs were analysed. 173 were treated with a single burr-hole (we called these Group 1) and 32 with double burr-holes (Group 2). No differences in preoperative characteristics were found between the groups, except for diabetes mellitus and previous antiplatelet/anticoagulation treatment. No radiological differences were found regarding haematoma volume (p = 0.7) or thickness (p = 0.3). Surgical site infection (p = 0.13), recurrence (p = 0.6), acute rebleeding (p = 0.25) and mortality (p = 0.94) were assessed without evidencing statistically significant differences. At the time of hospital discharge, most patients showed a remarkable clinical improvement, regardless of the number of burr-holes made (p = 0.7). CONCLUSIONS: This study suggests that cSDH can be efficiently evacuated by a single burr-hole craniostomy, a less invasive and shorter surgical procedure with quite good clinical outcomes and a low rate of complications.

Dexamethasone enhances the efficacy of atorvastatin in inhibiting excessively inflammation-induced abnormal angiogenesis by regulating macrophages.

BACKGROUND: We have recently showed that atorvastatin (ATO) combined with low dose of dexamethasone (DEX) was more efficacious in treating patients with chronic subdural haematoma (CSDH) than ATO monotherapy. This study was designed to investigate the underlying mechanisms of the improved efficacy of this combined therapy. METHODS: Mass spectrometry was performed to quantitatively detect drugs in haematoma fluids and serum samples from CSDH patients and also in cultured macrophages after treatment with either ATO alone or in combination with DEX. The differentiation and apoptosis of macrophages were evaluated using flow cytometry. The expression of cytokines, chemokines and angiogenesis-related proteins was evaluated using proteome profile arrays, immunoblots and ELISA, respectively. RESULTS: ATO was detected in haematoma fluids and serum samples, whose levels were increased significantly in samples collected from patients treated with both ATO and DEX. ATO was also increased in cultured macrophages treated with ATO and DEX. The numbers of M1-polarized macrophages were higher than the M2 phenotype in the haematoma fluids of patients. Cultured macrophages treated with ATO and DEX had reduced numbers of M1-polarized macrophages, increased numbers of M2-polarized macrophages as compared to monotherapies, and decreased rate of apoptosis induced by high-dose DEX. DEX enhanced the anti-inflammatory and anti-angiogenic activity of ATO by suppressing VEGFA and other inflammatory angiogenic factors. Consistent with the finding, patients responded well to the drug treatments had lower serum levels of VEGFA. CONCLUSIONS: We have shown for the first time that ATO given orally was detected in CSDH haematoma fluids. DEX enhances the anti-inflammatory and anti-angiogenic effects of ATO, primarily by increasing the presence of ATO in haematoma and macrophages and by regulating the functions of macrophages.

Risk factors for need of reoperation in bilateral chronic subdural haematomas.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most common neurosurgical diseases. A subtype of CSDH is bilateral chronic subdural haematoma (bCSDH) which represents 20-25% of patients with CSDH and has a higher recurrence rate. There is no clear consensus on how bCSDH should be treated regarding upfront unilateral- or bilateral evacuation of both haematomas. The purpose of this study was to identify risk factors associated with reoperation of bCSDH. METHODS: A total of 326 patients with radiological evidence of bCSDH were included in this retrospective cohort study where 133 (40.8%) patients underwent primary bilateral evacuation and 193 (59.2%) primary unilateral evacuation. The two centres operated using different surgical approaches. Analyses were performed to identify risk factors associated with reoperation of bCSDH. Reoperation rate was defined as reoperation of CSDH on either side of the hemisphere within 3 months after primary evacuation. RESULTS: The cohort had a total reoperation rate of 26.4%. Patients which underwent unilateral evacuation had a reoperation rate of 32.1%, and the bilateral group had a reoperation rate of 18.0% (p=0.005). Multivariable logistic regression identified unilateral evacuation (OR 1.91, p=0.022) and complications according to Ibanez (OR 2.20, p=0.032) to be associated with the need of reoperation of bCSDH. One-burr hole craniostomy with active subgaleal drain was primarily performed in bilateral approach (69.4%) whereas patients operated with minicraniotomy with passive subdural drain were primarily operated by unilateral evacuation of the larger symptomatic side (92.8%). CONCLUSIONS: Unilateral evacuation of bCSDH was associated with a higher risk for reoperation than upfront bilateral evacuations in this study. There is a need to further discuss the criteria for uni- or bilateral evacuation since patients are treated differently at different centres.

Incidence of chronic subdural haematoma: a single-centre exploration of the effects of an ageing population with a review of the literature.

BACKGROUND: Chronic subdural haematoma (cSDH) is a common neurosurgical pathology frequently occurring in older patients. The impact of population ageing on cSDH caseload has not been examined, despite relevance for health system planning. METHODS: This is a single-centre study from the UK. Operated cases of cSDH (n = 446) for 2015-2018 were identified. Crude and directly standardised incidence rates were calculated. Medline and EMBASE were systematically searched to identify studies reporting on the incidence of cSDH by year, so an estimate of rate of incidence change could be determined. Local incidence rates were then applied to population projections for local catchment area to estimate operated cSDH numbers at 5 yearly intervals due to shifting demographics. RESULTS: We identified nine studies presenting incidence estimates. Crude estimates for operative cases ranged from 1.3/100,000/year (1.4-2.2) to 5.3/100,000/year (4.3-6.6). When non-operated cases were included, incidence was higher: 8.2/100,000/year (6.0-11.2) to 48/100,000/year (37.7-61.1). Four pairs of studies demonstrated incidence rate increases of 200-600% over the last 50 years, but data was deemed too heterogeneous to generate formal estimate of incidence change. Local crude incidence of operated cSDH was 3.50/100,000/year (3.19-3.85). Directly standardised incidence was 1.58/100,000/year (1.26-1.90). After applying local incidence rates to population projections, case numbers were predicted to increase by 53% over the next 20 years. CONCLUSIONS: The incidence of cSDH is increasing. We project a 53% increase in operative caseload within our region by 2040. These are important findings for guiding future healthcare planning.

Surgical occlusion of middle meningeal artery in treatment of chronic subdural haematoma: anatomical and technical considerations.

BACKGROUND: The primary aim of chronic subdural haematoma (CSDH) treatment is to relieve pressure to improve neurological symptoms. The secondary aim is to avoid recurrence. The blood supply from the middle meningeal artery (MMA) to the haematoma membranes has recently become a research target, to enhance our understanding of the processes leading to growth and re-growth of a CSDH. Several studies indicate that endovascular embolization of the MMA (eMMA) reduces recurrence rates, but this effect must be confirmed in a randomized controlled setting. Endovascular embolization is an advanced and costly procedure carrying a significant risk of embolism in the elderly. The aim of this study was to assess anatomical and technical aspects of surgical occlusion of the MMA (soMMA) via a single same-procedure burr hole, as an alternative to eMMA. METHOD: Technical aspects of soMMA were assessed using cadaver head dissection. MMA anatomy was examined by mapping the branching pattern and distribution of MMA in dry skulls, and CSDH position was investigated by analysis of computed tomography (CT) of CSDHs. Finally, we evaluated the possibility of CT-guided navigation to mark the branching point of the anterior MMA division on the skin. RESULTS: We established anatomical landmarks to locate the MMA and found that particularly the anterior MMA branch can be occluded through a single burr hole at the pterion during the same procedure as haematoma decompression. CT of 1454 CSDHs in 1162 patients showed that the CSDH was anteriorly located in 57.5% compared with posteriorly in only 3%. This correlated with the anterior branch of the MMA being dominant in 58% of dry skull samples examined. We further confirmed that the MMA can be localized by neuronavigation as an alternative to using anatomical landmarks and average measurements. CONCLUSION: A CSDH is mainly anteriorly located and supposedly primarily supplied by the anterior MMA branch. In a simulated setting, soMMA can be performed during the same procedure as haematoma decompression. A few reservations notwithstanding, we find that soMMA may be a viable alternative to eMMA in most CSDH cases and that soMMA should be further evaluated in a clinical setting.

Preoperative MRI characteristics predict chronic subdural haematoma postoperative recurrence: a meta-analysis.

PURPOSE: Prior studies have reported that preoperative T1 magnetic resonance imaging (MRI) signal iso- or hypointensity may indicate higher risk of postoperative chronic subdural haematoma recurrence (cSDH). The authors undertook a meta-analysis to determine whether preoperative MRI characteristics may predict recurrence and/or reoperation after initial surgical evacuation of cSDH. MATERIALS AND METHODS: Embase, PubMed and Cochrane Library were queried to find articles published after 1990 that included data on preoperative brain MRIs obtained prior to burr hole or craniotomy haematoma evacuation of unilateral or bilateral cSDH and data on postoperative recurrence and/or repeat evacuation. The authors specifically investigated the T1 signal characteristics of the haematoma as they related to postoperative recurrence. RESULTS: Five articles were identified that included preoperative MRI T1 signal characteristics and postoperative recurrence data. One study reported cSDH recurrence requiring reoperation as the primary outcome, whereas four studies reported SDH recurrence alone as the primary outcome. A total of 1081 patients with a total of 1290 cSDHs underwent surgical evacuation. In the combined analysis, there were 62 recurrences in 300 cases (20.7%) in the MRI T1 hypo- and/or iso-intensity groups and 59 recurrences in 885 cases (6.7%) in the MRI T1 other groups (combined odds ratio = 4.385 (95% CI 2.93-6.57)). There was low heterogeneity among studies (i2 = 0%). CONCLUSION: This meta-analysis suggests that preoperative MRI T1 hypo- or isointensity cSDH signal may predict increased postoperative SDH recurrence risk.

Ruptured intra-cranial arachnoid cysts: a case series from a single UK institution.

INTRODUCTION: Intracranial arachnoid cysts are a common incidental finding; however presentation with cyst rupture is a recognised complication. Patients are advised to avoid contact sports to reduce the risk of cyst rupture but the risk of rupture is not currently known. The aim of this study is to describe a single institution's experience of managing ruptured intra-cranial arachnoid cysts. METHOD: A retrospective case note review of all patients admitted to a single institution with a ruptured intra-cranial arachnoid cyst between 2005 and 2016 (inclusive). Medical records were reviewed for demographics, history of trauma, surgical treatment and radiological evidence of cyst rupture. RESULTS: Fourteen patients were identified for inclusion with an average age of 23.4 years (range 7-57) and 10 (71%) were male. Nine patients (64%) had a documented history of head trauma. Eleven patients (78.6%) required neurosurgical intervention which included hygroma/haematoma evacuation only (n = 5), haematoma evacuation with cyst fenestration (n = 4) and cyst fenestration/shunting only (n = 2). Twelve patients (85%) experienced full recovery and the remaining two had persisting headaches or neurological symptoms. DISCUSSION: Cyst rupture remains an uncommon cause for presentation with arachnoid cysts. However the majority are associated with head trauma and thus current advice to avoid contact sports seems justified.

Drains result in greater reduction of subdural width and midline shift in burr hole evacuation of chronic subdural haematoma.

BACKGROUND: Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome. METHODS: A multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression. RESULTS: Three hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus 'no drain' groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome. CONCLUSIONS: The use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use.

Burr hole trepanation and insertion of a subperiosteal drain for chronic subdural haematoma: how I do it.

BACKGROUND: Burr hole trepanation (BHT) is the most commonly used surgical method for the treatment of chronic subdural haematoma (cSDH). METHOD: We give a brief overview on the indication for surgical treatment of cSDH, the surgical technique of BHT, and specific perioperative considerations. In particular, we emphasise on the technique of a subperiosteal drain placement. CONCLUSION: BHT is a valid option to treat chronic subdural haematoma. Careful surgical technique and placement of a subperiosteal drain is required to minimise complications and improve outcome.

Systematic review of current randomised control trials in chronic subdural haematoma and proposal for an international collaborative approach.

BACKGROUND: Chronic subdural haematoma (CSDH) is a pathology that is frequently encountered by neurosurgeons. Nevertheless, there is a lack of guidelines based on solid evidence. There has been a recent and considerable increase in the interest on management and outcomes for CSDH. Therefore, we systematically reviewed all currently running randomised controlled trials (RCTs) in chronic subdural haematoma to understand the areas under investigation and plan future collaborative trials. METHODS: Clinical trials databases (Cochrane Controlled Register of Trials, WHO ICTRP and clinical trials.gov) were searched for trials relevant to chronic subdural haematoma. It was then established which trials were currently running and fulfilled robust research methodology for a RCT. RESULTS: There are 26 currently running RCTs in CSDH, with the most common topics covering application of steroids (7), surgical techniques (5) and tranexamic acid (5). Further to this, there are trials running on other pharmacological agents (4), middle meningeal artery (MMA) embolisation (2) and peri-operative management (3). CONCLUSIONS: Pharmacological agents are a particular focus of CSDH management currently, and a wealth of studies on steroids will hopefully lead to more harmonised, evidence-based practice regarding this in the near future. Surgical techniques and new procedures such as MMA embolisation are also important focuses for improving patient outcomes. There is an on-going need for future RCTs and evidence-based guidelines in CSDH, particularly including low- and middle-income countries, and it is hoped that the establishment of the iCORIC (International COllaborative Research Initiative on Chronic Subdural Haematoma) will help address this.