Evaluation of Peripheral Blood Inflammatory Markers in Patients with Chronic Subdural Hematoma.

BACKGROUND AND AIM: Chronic subdural hematoma (CSH) refers to intracranial hemorrhages frequently caused by minor head trauma and is mostly seen in middle and advanced age. One of the hypotheses regarding the development of CSH is that the inflammatory cascade plays a pivotal role in this process. MATERIALS AND METHODS: The inclusion criteria covered patients in all ages who were diagnosed as CSH by computed tomography and/or magnetic resonance imaging and treated by surgical intervention in our clinic between 2018 and 2020. Patient files were reviewed retrospectively, and medical records of age, gender, trauma history, unilateral or bilateral lesion, and leukocyte, neutrophil, lymphocyte, monocytes, and platelet counts were obtained. Receiver operating characteristic (ROC) analysis was used for the most appropriate neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and age discrimination in the presence of CSH, and multiple logistic regression analyses were used to determine the effect of independent factors on dependent variables. RESULTS: A total of 68 cases, 57 (83.8%) male and 11 (16.2%) female, aged between 13 and 93, were included in the study. The mean age of the patients included in the study was 72.59 ± 13.13 years. NLR of the cases ranged from 1.37 to 34.18, with a mean of 6.53 ± 6.74 and a median of 3.57. NLR and PLR were found to be statistically significantly higher in CSH patients compared to the healthy control group, and the cut-off values for NLR, PLR, and age were 2.8, 132, and 55, respectively. Age and NLR were found to be independent factors associated with CSH (P < 0.05). CONCLUSION: As seen from the results of this study, peripheral blood values in CSH patients may be significantly higher than in the healthy control group, while they are below the normal laboratory cut-off values.

Middle Meningeal Artery Embolization for Management of Chronic Subdural Hematoma.

Chronic subdural hematoma (CSDH) is a prevalent medical condition with potentially severe consequences if left untreated. While surgical removal has traditionally been the standard approach for treatment, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive alternative to reduce recurrences. This comprehensive review provides the general radiology community with an overview of MMA embolization as a therapeutic option for managing CSDH. The authors base their insights on existing evidence and their institutional experience. This overview encompasses the pathophysiology of CSDH as well as the potential advantages and limitations, safety profile, and potential complications of MMA embolization as compared with surgical treatment. The imaging findings seen before and after MMA, as well as insights into the procedural techniques used at the authors' institution, are described. On the basis of reports in the current literature, MMA embolization appears to be a safe and effective therapeutic option for managing CSDH, especially in patients who are unsuitable for surgery or at risk for recurrence. Nonetheless, further research is needed to validate these findings. Results from ongoing clinical trials hold promise for future validation and the establishment of scientific evidence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chatterjee in this issue.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography.

PURPOSE: The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS: A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS: Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION: The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Are there characteristic indicators for increased pressure in chronic subdural hematoma?

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical disorders. However, no study has yet documented biomarkers indicating increased CSDH pressure. This study aimed to explore such indicators. A total of 50 patients underwent measurement for CSDH pressure during burr-hole irrigation. The mean hematoma pressure was 16.8 ± 7.6 cmH2O with no significant difference between new-onset and recurrent CSDHs. In 12 patients with a CSDH pressure ≥25 cmH2O, further analyses were carried out. Eight of them had bilateral CSDHs. All six patients with a CSDH pressure ≥28 cmH2O suffered headaches before surgery. Two out of three patients with a CSDH pressure ≥29 cmH2O felt nauseous. In statistical analyses, headache was positively correlated with a high CSDH pressure, whereas age and hematoma thickness were negatively correlated with it. Patients' sex, initial Glasgow coma scale score, motor weakness, midline shift on computed tomography scans, and administration of anticoagulants/antiplatelet agents, showed no significant correlation. When patients with bilateral CSDHs are not older adults and suffering headaches, an increased CSDH pressure should be assumed. For such patients, a prompt hematoma evacuation is indicated.

AI-Based Approach to One-Click Chronic Subdural Hematoma Segmentation Using Computed Tomography Images.

This paper presents a computer vision-based approach to chronic subdural hematoma segmentation that can be performed by one click. Chronic subdural hematoma is estimated to occur in 0.002-0.02% of the general population each year and the risk increases with age, with a high frequency of about 0.05-0.06% in people aged 70 years and above. In our research, we developed our own dataset, which includes 53 series of CT scans collected from 21 patients with one or two hematomas. Based on the dataset, we trained two neural network models based on U-Net architecture to automate the manual segmentation process. One of the models performed segmentation based only on the current frame, while the other additionally processed multiple adjacent images to provide context, a technique that is more similar to the behavior of a doctor. We used a 10-fold cross-validation technique to better estimate the developed models' efficiency. We used the Dice metric for segmentation accuracy estimation, which was 0.77. Also, for testing our approach, we used scans from five additional patients who did not form part of the dataset, and created a scenario in which three medical experts carried out a hematoma segmentation before we carried out segmentation using our best model. We developed the OsiriX DICOM Viewer plugin to implement our solution into the segmentation process. We compared the segmentation time, which was more than seven times faster using the one-click approach, and the experts agreed that the segmentation quality was acceptable for clinical usage.

The value of computed tomography texture analysis in identifying chronic subdural hematoma patients with a good response to polytherapy.

This study aimed to investigate the predictive factors of therapeutic efficacy for chronic subdural hematoma (CSDH) patients receiving atorvastatin combined with dexamethasone therapy by using clinical imaging characteristics in conjunction with computed tomography (CT) texture analysis (CTTA). Clinical imaging characteristics and CT texture parameters at admission were retrospectively investigated in 141 CSDH patients who received atorvastatin combined with dexamethasone therapy from June 2019 to December 2022. The patients were divided into a training set (n = 81) and a validation set (n = 60). Patients in the training data were divided into two groups based on the effectiveness of the treatment. Univariate and multivariate analyses were performed to assess the potential factors that could indicate the prognosis of CSDH patients in the training set. The receiver operating characteristic (ROC) curve was used to analyze the predictive efficacy of the significant factors in predicting the prognosis of CSDH patients and was validated using a validation set. The multivariate analysis showed that the hematoma density to brain parenchyma density ratio, singal min (minimum) and singal standard deviation of the pixel distribution histogram, and inhomogeneity were independent predictors for the prognosis of CSDH patients based on atorvastatin and dexamethasone therapy. The area under the ROC curve between the two groups was between 0.716 and 0.806. As determined by significant factors, the validation's accuracy range was 0.816 to 0.952. Clinical imaging characteristics in conjunction with CTTA could aid in distinguishing patients with CSDH who responded well to atorvastatin combined with dexamethasone.

Charlson Comorbidity Index and Frailty as Predictors of Resolution Following Middle Meningeal Artery Embolization for Chronic Subdural Hematoma.

BACKGROUND: Research on variables associated with chronic subdural hematoma (cSDH) resolution following middle meningeal artery embolization (MMAE) is limited. This study investigated the clinical utility of age-adjusted Charlson Comorbidity Index (ACCI) and modified 5-item Frailty Index (mFI - 5) for predicting cSDH resolution following MMAE. METHODS: We identified patients who underwent MMAE at our institution between January 2018 and December 2022, with at least 20 days of follow-up and one radiographic follow-up study. Patient demographics, characteristics, and outcomes were collected. Complete resolution was defined as absence of subdural collections on CT-scan at last follow-up. Nonage adjusted CCI (CCI), ACCI, and mFI - 5 scores were calculated. Univariate and multivariable logistic regression analyzed the relationship between cSDH resolution and variables. A receiver operating characteristic (ROC) curve established the utility of ACCI and mFI - 5 in predicting hematoma resolution. RESULTS: The study included 85 MMAE procedures. In univariate analysis, patients without resolution were older, had higher CCI, higher ACCI, higher mFI - 5, and were more likely to have diabetes mellitus. In multivarible analysis, CCI (OR: 0.66, 95% CI: 0.48, 0.91) was independently associated with resolution controlling for age and antithrombotic resumption. The area under the ROC (AUROC) curve was 0.75 (95% CI: 0.65-0.85) for ACCI and 0.64 (95% CI: 0.52-0.76) for mFI - 5. The optimal cutoffs for predicting resolution were ACCI ≥5 (sensitivity = 0.63, specificity = 0.77), and mFI - 5 > 0 (sensitivity = 0.84, specificity = 0.43). CONCLUSIONS: ACCI and mFI - 5 moderately predict MMAE resolution and may aid in medical decision-making.

Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial.

BACKGROUND: The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH. METHODS: The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure. DISCUSSION: We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation. TRIAL REGISTRATION: ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

Granuloma formation as a late complication of burr-hole surgery for chronic subdural hematoma.

BACKGROUND: Surgical treatment remains the mainstream therapeutic regimen for chronic subdural hematoma (CSDH), and burr-hole craniostomy with subdural drainage is the preferable approach. Herein, we reported a case of intracranial granuloma formation as a late complication of burr-hole surgery for CSDH. CASE PRESENTATION: A 31-year-old man presented with a 1-month history of headache. Head computed tomography (CT) showed a subdural hematoma in the left frontal-temporal-parietal region with significant midline shifting. A burr-hole evacuation of the hematoma with closed-system drainage was performed. CT obtained immediately after the surgery demonstrated that the hematoma was mostly evacuated. Nine months later, he presented to us again due to intermittent headache in the left temporoparietal region. Brain magnetic resonance imaging revealed a space-occupying mass at the site of the original hematoma. A bone-flap craniotomy was performed for resecting the mass. Histopathological examination revealed a granuloma. The microbial cultivation of the resected specimen was negative. The postoperative course was uneventful, and the headache was relieved. CONCLUSION: Granuloma formation is an extremely rare late complication of burr-hole surgery for CSDH. Physicians involved in the perioperative management of CSDH should be aware of this condition, and bone-flap craniotomy may be warranted.

Automated Preoperative and Postoperative Volume Estimates Risk of Retreatment in Chronic Subdural Hematoma: A Retrospective, Multicenter Study.

BACKGROUND AND OBJECTIVES: Several neurosurgical pathologies, ranging from glioblastoma to hemorrhagic stroke, use volume thresholds to guide treatment decisions. For chronic subdural hematoma (cSDH), with a risk of retreatment of 10%-30%, the relationship between preoperative and postoperative cSDH volume and retreatment is not well understood. We investigated the potential link between preoperative and postoperative cSDH volumes and retreatment. METHODS: We performed a retrospective chart review of patients operated for unilateral cSDH from 4 level 1 trauma centers, February 2009-August 2021. We used a 3-dimensional deep learning, automated segmentation pipeline to calculate preoperative and postoperative cSDH volumes. To identify volume thresholds, we constructed a receiver operating curve with preoperative and postoperative volumes to predict cSDH retreatment rates and selected the threshold with the highest Youden index. Then, we developed a light gradient boosting machine to predict the risk of cSDH recurrence. RESULTS: We identified 538 patients with unilateral cSDH, of whom 62 (12%) underwent surgical retreatment within 6 months of the index surgery. cSDH retreatment was associated with higher preoperative (122 vs 103 mL; P < .001) and postoperative (62 vs 35 mL; P < .001) volumes. Patients with >140 mL preoperative volume had nearly triple the risk of cSDH recurrence compared with those below 140 mL, while a postoperative volume >46 mL led to an increased risk for retreatment (22% vs 6%; P < .001). On multivariate modeling, our model had an area under the receiver operating curve of 0.76 (95% CI: 0.60-0.93) for predicting retreatment. The most important features were preoperative and postoperative volume, platelet count, and age. CONCLUSION: Larger preoperative and postoperative cSDH volumes increase the risk of retreatment. Volume thresholds may allow identification of patients at high risk of cSDH retreatment who would benefit from adjunct treatments. Machine learning algorithm can quickly provide accurate estimates of preoperative and postoperative volumes.

The effect of patient age on the degree of midline shift caused by chronic subdural hematomas: a volumetric analysis.

OBJECTIVE: Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH. METHODS: The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis. RESULTS: Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001). CONCLUSIONS: For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.

Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes.

BACKGROUND: Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. MATERIAL AND METHODS: A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. RESULTS: A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. CONCLUSION: MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.

Clinical Characteristics and Prognoses of Chronic Subdural Hematoma Patients with and without Head Trauma: A Retrospective Comparative Study.

OBJECTIVE: Head trauma is considered as the main cause of chronic subdural hematoma (CSDH). However, many patients develop CSDH with no identified cause. Herein, we conduct a comparative study to investigate the differences in clinical characteristics and surgical outcomes of CSDH patients with and without a history of head trauma. METHODS: We retrospectively reviewed CSDH patients who underwent surgical treatment in our hospital between January 2013 and December 2021. Patients were categorized into a with head trauma (WHT) group and a without head trauma (WOHT) group for comparative analysis. RESULTS: A total of 219 patients were included, 119 (54.3%) cases in the WHT group and 100 (45.7%) cases in the WOHT group. More cancer patients were found in the WOHT group than in the WHT group (P = 0.045). Both at discharge and 6-month follow-up, patients in the WOHT group achieved better clinical outcomes than the WHT group cases (P = 0.025 and 0.034, respectively). Furthermore, ordered multiclass logistic regression analyses indicated that a history of head trauma (odds ratio 2.151, 95% confidence interval 1.052-4.386; P = 0.036) was a risk factor significantly related to the unfavorable outcomes at 6-month follow-ups of CSDH. However, we did not find significant differences between the 2 groups in clinical manifestations, radiological characteristics, postoperative complications, mortality, and recurrence rates. CONCLUSIONS: CSDH patients with a history of head trauma may be more susceptible to unfavorable outcomes; thus, they should be carefully evaluated and given more attention during hospitalization and after discharge.

Chronic subdural haematoma mimicking extrapyramidal symptoms.

A male patient in his 70s with chronic schizophrenia, who could previously walk independently, developed a gait disturbance without any significant neurological deficit. Initially, his short step length and unstable gait were thought to be related to extrapyramidal symptoms caused by medication side effects. We tapered his antipsychotic medication, but the unstable gait persisted. After 2 weeks of observation, we noted general weakness with left-side dominance, leading us to consider a focal brain lesion despite there being no recent history of falling or trauma. A CT scan of the brain showed chronic subdural haematoma and the patient underwent emergency surgery. After 14 days of treatment, he was discharged back to the chronic ward.

Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematomas: A New-Old Treatment.

Chronic subdural hematoma (cSDH) is defined as a subdural collection of blood on CT imaging that tends to persist and gradually increase in volume over time, with components that are hypodense or isodense compared to the brain. There are no proven guidelines for the management of patients with cSDH. Surgical approaches included burr hole, twist drill hole, and craniotomy-based evacuations. Outcomes after surgical removal is generally favorable, but cSDH tends to recur after the initial evacuation.Middle meningeal artery (MMA) embolization has been gaining increasing popularity among the treatments of cSDH. This is largely due to a growing population of patients with cSDH who are refractory to other treatments or in patients who present with multiple comorbidities or who are taking antiplatelet and anticoagulant medications. The goal of middle meningeal artery (MMA) embolization is to devascularize subdural membranes associated with SDH so that the balance between continued leakage and reabsorption is shifted toward reabsorption.We discuss our clinical and technical approach to cSDH treated with perioperative embolization of the MMA.

Quantitative DECT of Iodine in Chronic Subdural Hematoma as Surrogate of Membrane Exudation: A Pilot Feasibility Study.

OBJECTIVE: We explore the feasibility to estimate the exudation from chronic subdural hematoma (CSDH) membranes, by using dual-energy computed tomography (DECT) quantification of iodine leak and test if the derived quantitative variables and membrane morphology correlates with hematoma volume, internal architecture (homogeneous, laminar, separated, and trabecular types), and fractional hyperdense hematoma at presentation. METHODS: In this retrospective study, consecutive CSDH patients with postcontrast DECT head images from January 2020 and June 2021 were analyzed. Predictor variables derived from DECT were correlated with outcome variables followed by mixed-effects regression analysis. RESULTS: The study included 36 patients with 50 observations (mean age, 72.6 years; standard deviation, 11.6 years); 31 were men. Dual-energy CT variables that correlated with hematoma volume were external membrane volume (ρ, 0.37; P = 0.008) and iodine concentration (ρ, -0.29; P = 0.04). Variables that correlated with separated type of hematoma were total iodine leak (median [Q 1 , Q 3 ], 68.3 mg [48.5, 88.9] vs 38.8 mg [15.5, 62.9]; P = 0.001) and iodine leak per unit membrane volume (median [Q 1 , Q 3 ], 16.47 mg/mL [10.19, 20.65] vs 8.68 mg/mL [5.72, 11.41]; P = 0.002). Membrane grade was the only variable that correlated with fractional hyperdense hematoma (ρ, 0.28; P = 0.05). Regression analysis showed total iodine leak as the strongest predictor of separated type hematoma (odds ratio [95% confidence interval], 1.06 per mg [1.01, 1.1]). CONCLUSIONS: Dual-energy CT demonstrates iodine leak from CSDH membranes. The variables derived from DECT correlated with hematoma volume, internal architecture, and fractional hyperdense hematoma.

Identification of Radiological and Clinical Factors that Increase the Risk of Chronic Subdural Hematoma Recurrence.

AIM: To determine risk factors predicting chronic subdural hematoma (CSH) recurrence is a common type of intracranial hemorrhage in elderly patients. Despite improved medical diagnosis and treatment, the reoperation rate remains high. MATERIAL AND METHODS: A retrospective review of 291 CSH patients admitted to our department was performed. Clinical and radiological factors predictive for CSH recurrence were identified by univariate analyses; variables whose p-value was < 0.05 underwent multivariate logistic regression analyses. RESULTS: Univariate analyses revealed that preoperative midline shift (p=0.025), mix-density hematoma (p=0.023), internal architecture of hematoma (p=0.044), membranectomy (p=0.001), and ambient cistern compression (p=0.001) correlated with a significantly higher rate of recurrence. Multivariate analyses showed that separated architecture, membranectomy and ambient cistern compression were independent risk factors for CSH recurrence. CONCLUSION: Among many factors, membranectomy, separated architecture, and ambient cistern compression were the strongest predictors for recurrence.