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

INTRODUCTION: Acute subdural hemorrhage (ASDH) from traumatic brain injury is a life-threatening situation, often requiring surgical intervention. This meta-analysis is done to update the literature regarding the choice of procedure for the treatment of ASDH. METHODS: PubMed, Scopus, and Cochrane were searched from the year 2000 up to September 2023. Randomized controlled trials and observational studies were included. The odds ratio with 95% confidence interval (CI) mean difference and standardized mean difference were calculated for dichotomous and continuous outcomes, respectively. RESULTS: A total of 14 studies comprising 4686 patients were included in the analysis. Pooled Glasgow Outcome Scale/Extended Glasgow Outcome Scale scores were compared based on their means, with the craniotomy (CO) group having better mean scores than decompressive craniectomy (DC) (standardized mean difference -0.37, 95% CI -0.68 to -0.06, P = 0.02). The risk for poor outcomes was statistically greater in the DC group compared to the CO group (1.32, 95% CI 1.05-1.66, P value = 0.02). There were fewer residual subdural hematoma cases in the DC group as compared to CO (odds ratio 0.40, 95% CI 0.22-0.73, P value < 0.005). CONCLUSIONS: Our meta-analysis showed that the ASDH patients had better functional outcomes when treated with CO as compared to DC. However, there were fewer odds of residual subdural hematoma with DC.

Comparative clinical outcomes of irrigation techniques in burr-hole craniostomy for chronic subdural hemorrhage: a multicenter cohort study.

BACKGROUND: Chronic Subdural Hemorrhage(cSDH) is often treated with surgical blood drainage, but concerns about recurrence and outcomes persist. Surgical techniques, including irrigation, vary. This study compares the outcomes of irrigation in cSDH surgery. MATERIALS AND METHODS: From September 2020 to September 2022, 92 cSDH patients underwent surgery. Two different irrigation methods were used: extensive irrigation (IG) and non-irrigation (NIG). Method of irrigation was selected by each surgeon's preference. Parameters measured included volume of hematoma changes, midline shifting, complications, and basic demographics. Recurrence was defined as symptomatic or hematoma expansion more than double the volume before surgery. Factors predicting recurrence and irrigation method impact were analyzed. RESULTS: Eleven patients were excluded because of bilateral or related to other disease. We analyzed 81 patients (44 NIG, 37 IG). Recurrence occurred in 6 IG cases (16.2%) and 1 NIG case (2.3%). Irrigation method significantly affected recurrence (P = 0.043). Age, gender, medication, medical history, and preoperative measurements had no major impact on recurrence. NIG had unexpected cases of intracerebral hemorrhage. CONCLUSION: Extensive irrigation may increase recurrence in cSDH drainage. Non-irrigation drainage had fewer recurrences, but unexpected complications arose. Careful drainage in non-irrigated cases is crucial.

Acute presentation of abusive head trauma.

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.

Birth-related subdural hemorrhage in asymptomatic neonates: evolution over time and differentiation from traumatic subdural hemorrhage.

BACKGROUND: Intracranial birth-related subdural hemorrhage frequently occurs in asymptomatic newborns and has no adverse long-term sequelae. It is medically and medicolegally important to differentiate birth-related subdural hemorrhage from other pathological causes of intracranial hemorrhage. There is limited literature available on the incidence of birth-related subdural hemorrhage, its imaging features, and evolution over time, mainly because asymptomatic infants do not routinely undergo cranial MRI. OBJECTIVE: To establish the incidence and distribution of birth-related subdural hemorrhage and evaluate their association with various modes of delivery, identify associated features, and evaluate the sequential evolution of signal changes of the birth-related hemorrhages on MRI. MATERIALS AND METHODS: A total of 200 healthy term neonates and young infants were included in this retrospective review study. All infants underwent MRI of the brain and cervical spine at postnatal age of 0-2 months with acquisition of a 3D T1-weighted (T1W), 3D or 2D T2-weighted (T2W), and axial diffusion-weighted imaging (DWI) sequences. The scans were evaluated for the presence and distribution of subdural hemorrhages, other intracranial hemorrhages, and associated injuries. Prevalence of intracranial hemorrhage in various modes of delivery was analyzed. Relationship between the signal intensities of the bleeds on T1W, T2W, and DWI scans and the age of the infants was analyzed. Appropriate tests were applied to test for statistical significance of the data. RESULTS: Out of 200 neonates, 66 (33%) had detectable intracranial hemorrhage on MRI with an age range of 11-25 days, including 31 (47%) males and 35 (53%) females. All of them had subdural hemorrhages, 54 (81.8%) of which were in the posterior fossa. Additional parenchymal hemorrhages were present in a few, but no subarachnoid hemorrhages, cervical spinal canal hemorrhages, cortical bridging vein injury, or cervical spinal ligamentous injury were identified within the limitations of the study. No detectable intracranial hemorrhage was found in subjects above 25 days of age. Overall incidence of subdural hemorrhage by mode of delivery was 8/68 (11.8%) in babies born by cesarean section and 58/132 (43.9%) in babies born by vaginal delivery. Among the vaginal deliveries, the highest incidence was observed in assisted vaginal delivery (19/30, 63.3%). Subjects with birth-related subdural hemorrhage were categorized into three age groups: <13 days, 13-21 days, and >21 days. All detected hemorrhages were T1W hyperintense. In the <13 days group, all bleeds were T2W hypointense. In the 13-21 days group, 73.1% were T2W hypointense, while 26.9% were T2W mixed. All bleeds in the >21 days group were T2W hypointense. All DWI hyperintense bleeds were found in the 13-21 days group. CONCLUSION: Birth-related subdural hemorrhage occurs in over a third of normal deliveries and has a characteristic distribution, predominantly in the posterior fossa. Associated cervical spinal subdural hemorrhages, cervical spinal ligamentous injury, or cortical bridging vein injury, which are concerning for traumatic etiology, were not identified. Birth-related subdural hemorrhages follow a characteristic pattern of signal changes on MRI. Although not completely reliable, this can help in differentiating them from traumatic intracranial hemorrhages which usually occur postnatally. No birth-related subdural hemorrhages were seen after 25 days of age in our cohort.

Macroscopic and histological examination of human bridging veins.

In infantile abusive head injury (AHT), subdural haemorrhage (SDH) is commonly held to result from traumatic damage to bridging veins traversing from the surface of the brain to the dura and dural venous sinuses. However, there are limited published radiological or autopsy demonstrations of ruptured bridging veins and several authors also assert that bridging veins are too large to rupture due to the forces associated with AHT. There have been several studies on the size, locations and numbers of adult bridging veins and there is one small study of infant bridging veins. However, there are no microscopic studies of infant bridging veins and only a select few ultrastructural investigations of adult bridging veins. Hitherto, it has been assumed that bridging veins from infants and younger children will display the same anatomical characteristics as those in adulthood. At 19 neonatal, infant and young child post-mortem examinations, we macroscopically examined and sampled bridging veins for microscopy. We compared the histology of those samples with bridging veins from an older child and two adults. We demonstrate that adult bridging veins are usually surrounded by supportive meningeal tissue that appears to be lacking or minimally present around the bridging veins of younger children. Neonatal, infant and young children's veins had a free 'bridging' section. Neonatal and infant bridging veins had smaller diameter ranges and thinner walls (some only 5-7 µm) than those seen in older children and adults. Bridging vein walls contained both fine strands of elastic fibers and a more pronounced elastic lamina. The presence of an elastic lamina occurred more frequently in the older age groups These anatomical differences between the veins of adults and young children may help to explain apparent increased vulnerability of neonatal/infant bridging veins to the forces associated with a shaking-type traumatic event.

Association of enlarged extra-axial spaces and subdural hemorrhage in preterm infants at term-equivalent age.

To determine the incidence of enlarged extra-axial space (EES) and its association with subdural hemorrhage (SDH) in a regional cohort of preterm infants. As part of a prospective cohort study of 395 preterm infants, brain magnetic resonance imaging (MRI) was collected on each infant at term-equivalent age. Six preterm infants showed evidence of SDH. We reviewed the MRIs to identify the incidence of EES in these 6 infants and the cohort broadly. We then completed a retrospective chart review of the 6 infants to identify any concerns for non-accidental trauma (NAT) since the MRI was obtained. The incidence of SDH in the cohort was 1.6%. The incidence of EES was 48.1% including all 6 infants with SDH. The incidence of SDH in infants with EES was 3.2%. The retrospective chart review of the 6 infants did not yield any evidence of NAT. The incidence of EES and SDH in our cohort was significantly higher than similar cohorts of term infants, demonstrating an increased risk in preterm infants. The incidence of SDH in infants with EES was greater than in the total cohort, suggesting that it is a risk factor for asymptomatic SDH in preterm infants.

The Delayed Presentation of Bilateral Subdural Hematoma Secondary to Epidural Anesthesia for Elective Vaginal Delivery: A Case Report and Review of the Literature.

Epidural anesthesia (EA) involves reaching the spinal epidural space with an anesthetic drug injection. This procedure provides pain relief during labor. Although EA can lead to some complications, subdural hemorrhage (SDH) is a rare adverse event associated with it. We report the case of a 25-year-old female patient who presented to our emergency department with a one-month history of headaches and associated blurred vision following a normal vaginal delivery with EA. She was initially treated as a case of post-dural puncture headache (PDPH), with no improvement. Finally, the diagnosis of bilateral SDH was made based on a brain MRI. She required surgical intervention, which led to a positive prognosis and a full return of normal baseline neurological functions. Only a few reports in the literature have indicated the possibility of cranial subdural hematoma formation associated with spinal or epidural analgesia. Our patient experienced a delay in her diagnosis and treatment, as SDH following EA is a rare entity. It is important to follow up with such patients and consider other possibilities when symptoms fail to resolve. Also, reporting these cases is crucial to assist clinicians in early diagnosis and treatment, and to avoid disastrous outcomes.

Non-traumatic Spinal Subdural Hemorrhage Associated With Rivaroxaban Use.

Spinal subdural hematoma (SSDH) is a rare medical emergency that can cause permanent neurological deficits. The disease is characterized by sudden onset back pain, sensorimotor changes, and bladder and autonomic dysfunction. This is often associated with the use of anticoagulants, blood dyscrasias, and recent spinal procedures. We present a case of a 63-year-old male maintained on rivaroxaban for nonvalvular atrial fibrillation clinically presenting with abrupt onset back pain that rapidly progressed to sensorimotor deficits and bladder dysfunction. Rivaroxaban, a selective inhibitor of factor Xa, has been approved by the Food and Drug Administration (FDA) for the reduction of stroke risk and systemic embolism in nonvalvular atrial fibrillation. We postulate that rivaroxaban played a major role in triggering the spinal hemorrhage. This case highlights the very limited documented cases of spontaneous subdural spinal hemorrhages associated with rivaroxaban use.

Association between Lipid-Lowering Drugs and Traumatic Subdural Hemorrhage: A Mendelian Randomization Study.

BACKGROUND: There are current clinical observations that atorvastatin may promote subdural hematoma resorption. We aimed to assess the causal effects of lipid-lowering agents 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) inhibitors, Proproteinconvertase subtilisin/kexin type 9 (PCSK9) inhibitors and Niemann-Pick C1-like protein 1 (NPC1L1) inhibitors on traumatic subdural hematomas. METHODS: We used genetic instruments to proxy lipid-lowering drug exposure, with genetic instruments being genetic variants within or near low-density lipoprotein (LDL cholesterol)-associated drug target genes. These were analyzed by using a two-sample Mendelian randomization (MR) study. RESULTS: A causal relationship was found between HMGCR inhibitors and traumatic subdural hematoma (Inverse variance weighted (ß = -0.7593341 (Odds Ratio (OR) = 0.4679779), p = 0.008366947 < 0.05)). However, no causal relationship was found between PCSK9 inhibitors and NPC1L1 inhibitors and traumatic subdural hematoma (PCSK9 inhibitors: Inverse variance weighted (ß = 0.23897796 (OR = 1.2699505), p = 0.1126327), NPC1L1 inhibitors: Inverse variance weighted (ß = -0.02118558 (OR = 0.9790373), p = 0.9701686)). Sensitivity analysis of the data revealed good stability of the results. CONCLUSIONS: This two-sample MR study suggests a potential causal relationship between HMGCR inhibition (atorvastatin) and traumatic subdural hemorrhage.

Navigating the Challenges of Delayed Subdural Hemorrhage and COVID-19: A Case Report.

The delayed onset of posttraumatic subdural hemorrhage (SDH) represents non-specific clinical features, complicating the diagnostic process, especially in individuals predisposed due to pre-existing risk factors and comorbidities. This case report delineates the medical trajectory of a 61-year-old female patient who sustained a traumatic fall, initially displaying neither clinical nor radiological signs indicative of hemorrhage. However, three weeks post-injury, she developed altered mental status, cephalgia, and emesis. Diagnostic imaging unveiled a significant bilateral acute-on-chronic subdural hemorrhage exerting pronounced mass effect and leading to obliteration of the basal cisterns. Complicating her clinical picture was a concurrent SARS-CoV-2 infection and a medical history of hypertension. Emergent neurosurgical intervention was undertaken, encompassing the creation of bilateral burr holes for drainage and the placement of subdural drains. The patient was managed with the requisite medical therapies. Post-operatively, the patient regained consciousness and exhibited significant neurological improvement. Follow-up imaging demonstrated complete resolution of the subdural hemorrhage, and the patient achieved a full recovery of cognitive function. This case underscores the critical necessity for vigilant surveillance for delayed SDH in patients lacking initial radiographic findings and advocates for individualized therapeutic approaches in patients with concurrent pathologies. Prompt recognition, timely neurosurgical management, and care are pivotal to optimizing outcomes in delayed posttraumatic SDH cases.

Intracranial hypotension with subdural hematoma after spinal anesthesia in obstetric patient: A rare but fatal complication.

Intracranial bleed in the form of subdural hematoma (SDH) with intracranial hypotension after spinal anesthesia for cesarean section is a rare condition with an incidence of around 1 in 5,00,000 obstetric populations. As its presentation is similar to post-dural puncture headache (PDPH), it can be misdiagnosed sometimes. Persistent headache for more than 5 days, vomiting, blurring of vision, and convulsion can guide the diagnosis of intracranial bleed. Magnetic resonance imaging (MRI) helps to diagnose the location, size, and other abnormalities of bleed in such patients. The management ranges from conservative to surgical management in the form of craniotomy. Here, we present a case of a 19-year-old woman, who operated on for cesarean section under spinal anesthesia presented with SDH and intracranial hypotension on postoperative day (POD) 6. She was managed conservatively with plenty of intravenous (IV) fluids, bed rest, low head position, analgesics, and antiepileptics. A repeat computed tomography (CT) scan was performed after 14 days, which showed resolved SDH, and the patient was discharged.

Massive spontaneous subdural hemorrhage mimicking dural venous thrombosis in a sickle cell adolescent, a rare case report.

INTRODUCTION: Sickle cell disease is one of the most common hemoglobinopathies in Africa. Tanzania alone accounts for about 11,000 sickle cell births annually making it one of the most common disorders in eastern Africa. The affected individuals are prone to several complications since childhood as a result of the defective hemoglobin structure, these include neurological complications such as ischemic stroke due to hypercoagulability state caused by the disease. Spontaneous intracranial hemorrhage such as subdural hemorrhage in the absence of predisposing factors such as trauma, anticoagulant use, or recent blood transfusions is rare. As reported in the previous literature. CASE PRESENTATION: We report a rare case of acute spontaneous subdural hemorrhage in an adolescent sickle cell patient of African descent. DISCUSSION: Initial management including early referral and medical treatment is crucial for cases that are suspicious of intracranial hemorrhage. These cases are more common to be missed in resource-limited settings where there are a limited number of neurosurgery interventions. CONCLUSION: Although few reported cases of spontaneous intracranial hemorrhage in sickle cell patients are reported, it is important to be vigilant as a clinician wherever a sickle cell patient presents with signs of increased intracranial pressure without a history of trauma such as in our patient and order an urgent brain imaging to rule out spontaneous hemorrhagic events which may lead to fatal consequences if missed out.

Late-onset aspirin-related hemolysis and subsequent subdural hemorrhage in patient with glucose-6-phosphate dehydrogenase deficiency.

Key Clinical Message: Aspirin-related hemolysis in G6PD deficiency could be late-onset during long-term administration. Hemolytic anemia could continue for a relatively long time in elder patient with G6PD deficiency, which might be related to other adverse events. Abstract: Aspirin-related hemolysis in G6PD-deficient individuals was generally reported among patients who received high-dose supplements within several days after ingestion. The safety of long-term and low-dose (50-325 mg/day) aspirin in patients coexist G6PD deficiency and cardiovascular disease is neglected in clinical practice. In this case, we observed a late-onset hemolysis and subsequent fatal subdural hemorrhage in one G6PD-deficient individual who had received long-term and low-dose aspirin. An 83-year-old male was diagnosed with acute ischemic stroke and treated with 100 mg/day aspirin at the emergency room. After admission, the patient was diagnosed with severe G6PD deficiency based on enzyme activity, but no hemolysis occurred within 10-day aspirin therapy in the hospital. Hence, 100 mg/day aspirin was continued on discharge. Two months later, the patient presented acute hemolysis manifested as fatigue, dark urine, and moderate jaundice. Although hemolysis was self-limit in a few days, hemoglobin decline continued for 20 days until a fatal subdural hemorrhage occurred. Our study indicated aspirin-related hemolysis could be late-onset in G6PD-deficient individual even receiving low-dose treatment and is probably linked to subsequent major bleeding events.

Efficacy of Child Abuse Evaluations for Infants With Possible Subdural Hemorrhage Identified on Cranial Ultrasound Completed for Macrocephaly.

Abusive head trauma (AHT) is a significant cause of morbidity and mortality for infants. Determining when to pursue a complete physical abuse evaluation can be difficult, especially for nonspecific findings or when a child appears clinically well. This retrospective study of 7 cases sought to describe the presentation, evaluation, and diagnoses for infants with abnormal subdural collections identified on cranial ultrasound for macrocephaly, and to determine how frequently AHT is diagnosed. The results of this study showed that while each patient presented due to asymptomatic macrocephaly, the extent of the workup varied greatly. In addition, no infants had suspicious injuries for abuse during the initial evaluation or the year following. In summary, among the 7 patients seen for asymptomatic macrocephaly with possible subdural hemorrhage, there were very inconsistent child abuse workups. There needs to be a standardized clinical guideline for this specific patient population involving a child abuse pediatric evaluation.

Temporal lobe uncal herniation with contralateral superior cerebellar artery infarct.

Herniation of the temporal lobe uncus typically leads to the compression of the ipsilateral oculomotor nerve, resulting in ipsilateral mydriasis, as well as compression of the ipsilateral posterior cerebral artery, leading to infarction in the posterior inferior temporal lobe and medial occipital cortex. In this report, we present the case of a 45-year-old man with a large left subdural hematoma. At autopsy, we observed left cingulate and uncal herniations, along with the characteristic lesions of Kernohan notch phenomenon due to compression of the contralateral cerebral peduncle. Additionally, a hemorrhagic infarct was identified in the right cerebellar hemisphere in the distribution of the superior cerebellar artery (SCA). This case provides the first autopsy report of uncal herniation with contralateral SCA infarct, an extremely rare condition. Importantly, this vascular complication may often go unnoticed in patients with Kernohan notch phenomenon although it may carry a grave clinical prognosis.

Cerebral sinovenous thrombosis as a cause of subdural hemorrhage in the pediatric population: Is there a correlation?

PURPOSE: Cerebral sinovenous thrombosis is an increasingly recognized cause of stroke in children and neonates. Its true incidence appears to be underestimated. Despite being a rare event, certain studies have found a correlation between subdural hemorrhage and cerebral sinus thrombosis. The literature suggests that spontaneous cerebral sinovenous thrombosis in the pediatric population may lead to the occurrence of a subdural hemorrhage. In this report, we present a case of cerebral venous thrombosis associated with chronic subdural hematoma and review the literature to highlight the importance of these conditions. CASE REPORT: An 11-year-old boy was admitted in the neurosurgery department with headache and a neurological examination without changes. The imaging studies identified a heterogeneous subdural collection in the fronto-temporo-parietal region. The patient underwent surgical drainage of the subdural hematoma, and the procedure was performed without complications. The magnetic resonance and angiography showed an extensive thrombosis of the superior sagittal sinus, extending downward to the occipital sinus and partially to the right transverse sinus. CONCLUSIONS: Appropriate management in the diagnosis and an early treatment of dural sinus thrombosis associated with subdural hemorrhage can reduce the risk of recurrence and improve the clinical outcome.

Subdural hemorrhage in middle cranial fossa arachnoid cysts: a report of two cases at two ends of the spectrum.

Arachnoid cysts are usually asymptomatic, benign lesions commonly occurring in the middle cranial fossa. However, the cysts may rupture in rare cases causing intracystic or subdural hemorrhages with significant mass effect. We report two cases of middle cranial fossa arachnoid cyst with subdural hemorrhage with very different clinical course. The first case presented with significant mass effect with cerebral herniation and had significant neurological morbidity post-surgery. The second case had minimal symptoms and was managed conservatively with offer of elective surgery. The report underscores the importance of prompt diagnosis and appropriate surgical intervention in managing arachnoid cysts with hemorrhage, highlighting the potential for diverse clinical presentations and outcomes.

Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage.

INTRODUCTION: Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes. METHOD: Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis. RESULTS: During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15. CONCLUSION: Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients.

Objective: We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management. Background: Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation. Methods: A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability. Results: Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata. Conclusion: Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

Peptidomics insights: neutrophil extracellular traps (NETs) related to the chronic subdural hemorrhage.

Chronic subdural hemorrhage (CSDH) refers to a hematoma with an envelope between the dura mater and the arachnoid membrane and is more common among the elderly. It was reported that the dura mater, which is highly vascularized with capillary beds, precapillary arterioles and postcapillary venules play an important role in the protection of the central nervous system (CNS). Numerous evidences suggests that peptides play an important role in neuroprotection of CNS. However, whether dura mater derived endogenous peptides participate in the pathogenesis of CSDH remains undetermined. In the current study, the peptidomic profiles were performed in human dura of CSDH (three patients) and the relative control group (three non-CSDH samples) by LC-MS (liquid chromatography-mass spectrometry). The results suggested that a total of 569 peptides were differentially expressed in the dura matter of CSDH compared with relative controls, including 217 up-regulated peptides and 352 down-regulated peptides. Gene Ontology (GO) analysis demonstrated that the precursor proteins of those differentially expressed peptides were involved in the various biological processes. Interestingly, Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis suggested that NETs participated in the pathogenies of CSDH. Further investigate showed that H3Cit was significantly elevated in the dural and hematoma membranes of patients with CSDH compared to patients without CSDH. Taken together, our results showed the differentially expressed peptides in human dura mater of CSDH and demonstrated that NETs formation in the dural and hematoma membranes might be involved in the pathogenesis of CSDH. It is worth noting that pharmacological inhibition of NETs may have potential therapeutic implications for CSDH.