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.

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.

External validation of prognostic models predicting outcome after chronic subdural hematoma.

BACKGROUND: Several prognostic models for outcomes after chronic subdural hematoma (CSDH) treatment have been published in recent years. However, these models are not sufficiently validated for use in daily clinical practice. We aimed to assess the performance of existing prediction models for outcomes in patients diagnosed with CSDH. METHODS: We systematically searched relevant literature databases up to February 2021 to identify prognostic models for outcome prediction in patients diagnosed with CSDH. For the external validation of prognostic models, we used a retrospective database, containing data of 2384 patients from three Dutch regions. Prognostic models were included if they predicted either mortality, hematoma recurrence, functional outcome, or quality of life. Models were excluded when predictors were absent in our database or available for < 150 patients in our database. We assessed calibration, and discrimination (quantified by the concordance index C) of the included prognostic models in our retrospective database. RESULTS: We identified 1680 original publications of which 1656 were excluded based on title or abstract, mostly because they did not concern CSDH or did not define a prognostic model. Out of 18 identified models, three could be externally validated in our retrospective database: a model for 30-day mortality in 1656 patients, a model for 2 months, and another for 3-month hematoma recurrence both in 1733 patients. The models overestimated the proportion of patients with these outcomes by 11% (15% predicted vs. 4% observed), 1% (10% vs. 9%), and 2% (11% vs. 9%), respectively. Their discriminative ability was poor to modest (C of 0.70 [0.63-0.77]; 0.46 [0.35-0.56]; 0.59 [0.51-0.66], respectively). CONCLUSIONS: None of the examined models showed good predictive performance for outcomes after CSDH treatment in our dataset. This study confirms the difficulty in predicting outcomes after CSDH and emphasizes the heterogeneity of CSDH patients. The importance of developing high-quality models by using unified predictors and relevant outcome measures and appropriate modeling strategies is warranted.

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.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

BACKGROUND: Criteria for diagnosing abusive head trauma (AHT) or "shaken baby syndrome" are not well defined; consequently, these conditions might be diagnosed on failing premises. METHODS: The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)-mean age 5.1 month, without age difference between genders. RESULTS: Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). CONCLUSIONS: BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors' experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score.

The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.

Presenting symptoms and functional outcome of chronic subdural hematoma patients.

BACKGROUND: Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes. OBJECTIVE: To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH. METHODS: We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders. RESULTS: We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4). CONCLUSION: Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.

Atorvastatin-Induced Absorption of Chronic Subdural Hematoma Is Partially Attributed to the Polarization of Macrophages.

As one of the main types of secondary craniocerebral injury, the onset, progression, and prognosis of chronic subdural hematoma (CSDH) are closely related to the local inflammation of intracranial hematoma. Atorvastatin is reported to be effective in the conservative treatment of CSDH. This study aimed to clarify whether atorvastatin regulated the inflammatory responses in CSDH by interfering with the function of macrophages. The rat CSDH model was prepared by repeated intracranial blood injection with velocity gradient, and MRI was applied to calculate the intracranial hematoma volume. Changes in rat nerve functions were evaluated by foot-fault and Morris water maze tests. Flow cytometry was applied to detect the number of total macrophages and the percentage of M1 or M2 macrophages. The expression of inflammatory factors was examined by ELISA and western blot. Western bolt was applied to detect the expression of proteins involved in the colony-stimulating factor 1 receptor (CSF-1R) signaling pathway. Our results showed that atorvastatin significantly accelerated the absorption of hematoma and improved the nerve functions of CSDH rats. In addition, atorvastatin treatment effectively suppressed the expression of TNF-α, IL-6, and IL-8 and promoted the expression of IL-10. The total number of macrophages was decreased, and the percentage of M2 macrophages was increased in the intracranial hematoma following atorvastatin treatment. Furthermore, atorvastatin increased the levels of M2-related genes and surface markers in BMDMs stimulated by lipopolysaccharides and IFNγ, and activated the CSF-1R signaling pathway. In conclusion, our study shows that atorvastatin could alleviate the symptoms of CSDH and promote hematoma ablation by polarizing macrophages to M2 type and regulating the inflammatory responses.

Clinical characteristics and outcomes of chronic subdural hematoma in patients with a history of antiplatelet therapy.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. Many patients with CSDH take antiplatelet (AP) drugs. Several studies have focused merely on the relationship between AP drug use and recurrence without deeply analyzing the specific clinical features of these patients. The primary objective of this study was to investigate the detailed clinical characteristics and outcomes of CSDH patients with a history of AP therapy. METHODS: A total of 1181 CSDH patients over 40 years of age who received burr-hole craniostomy were enrolled. Clinical information, computed tomographic findings, and data on long-term outcomes and recurrence among these patients were gathered. We divided these patients into two groups according to whether they had a history of AP therapy. Percentages and χ2 tests were applied for categorical variables. Standard deviations and 2-sided unpaired t-tests were applied for continuous variables. Univariate and multivariate logistic regression analyses were performed to identify independent factors of the outcomes (6 months after discharge). RESULTS: AP therapy was not related to the outcomes of patients with CSDH (P = 0.48), and there were no differences in recurrence between the AP and non-AP group. Only Bender grade (P < 0.01, B = -3.14, Exp (B) = 0.04, 95% CI 0.01-0.29) was associated with the outcomes of patients in the AP group. The incidence of complications in the AP group was higher than that in the non-AP group (P < 0.01). Postoperative thrombotic events may be more likely to occur in the AP group than in the non-AP group (P = 0.02). Patients in the AP group were older (P < 0.01) and had more comorbidities (P < 0.01). CONCLUSIONS: Patients treated with AP therapy had more complications. The outcomes of patients treated with AP therapy were associated with their status of admission. Patients treated with AP therapy were at greater risk for postoperative thrombotic events. The recurrence rate of CSDH did not appear to be affected by AP therapy.

Meningioma parasagital y hematoma subdural crónico, una asociación inusual / Parasagittal meningioma and chronic subdural hematoma, unusual association

RESUMEN En muchas ocasiones, los pacientes con tumores cerebrales tienen una variedad de síntomas psiquiátricos inespecíficos. Algunos de estos pueden constituir la primera o única manifestación del tumor, sin la presencia de ningún síntoma o signo neurológico. El diagnóstico ha de basarse en la anamnesis completa y en la exploración neurológica; la neuroimagen confirmará el diagnóstico clínico. Con el presente trabajo se describió la asociación inusual de hematoma subdural crónico y meningioma parasagital en un caso presentado. Se trató de un paciente de 68 años con antecedentes de esquizofrenia. Acudió a consulta con una hemiparesia izquierda. Se le realizó una tomografía axial computarizada de cráneo y arrojó un hematoma subdural crónico y un meningioma parasagital derecho. Se le aplicó tratamiento quirúrgico en dos tiempos operatorios. Su evolución posquirúrgica transcurrió sin complicaciones (AU).

ABSTRACT In many cases, patients with brain tumors have a variety of nonspecific psychiatric symptoms. Some of them can be the first or the only manifestation of the tumor, without presenting any neurological signs or symptoms. The diagnosis must be based on the complete anamnesis and on the neurological examination. The neuroimaging will confirm the clinical diagnosis. The unusual association of a chronic subdural hematoma and a parasagittal meningioma was described in a case presented in the current work. It dealt with a patient, aged 68 years with antecedents of schizophrenia. He assisted the consultation with left hemiparesis. A skull computed tomography showed a chronic subdural hematoma and a right parasagittal meningioma. He underwent a two-steps surgery. His post-surgery evolution ran without complications (AU).

Management of chronic subdural hematoma with the subdural evacuating port system: Systematic review and meta-analysis.

The subdural evacuating port system (SEPS) is a minimally invasive option for treating chronic subdural hematoma (cSDH). Individual case series have shown it to be safe and effective, but outcomes have not been systematically reviewed. We sought to review the literature in order to determine the safety and efficacy of SEPS as a first line treatment for cSDH. A comprehensive literature search for outcomes following SEPS placement as a primary treatment for cSDH was performed. The primary outcome was treatment success, which was defined as a composite of improvement in presenting symptoms and no need for further treatment in the operating room. Additional outcomes included discharge disposition, length of stay (LOS), hematoma recurrence, and complications. A total of 12 studies comprising 953 patients who underwent SEPS placement met the inclusion criteria. The pooled rate of a successful outcome was 0.79 (95% CI 0.75-0.83). Frequency of delayed hematoma recurrence was 0.15 (95% CI 0.10-0.21). The pooled inpatient mortality rate was 0.02 (95% CI 0.01-0.03). Complications rates included 0.02 (95% CI 0.00-0.03) for any acute hemorrhage, 0.01 (95% CI 0.00-0.01) for acute hemorrhage requiring surgery, and 0.02 (95% CI 0.01-0.03) for seizure. SEPS placement is associated with a success rate of 79% and very low rates of acute hemorrhage and seizure. This data supports its use as a first-line management strategy, although prospective randomized studies are needed.

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

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

Supervised Valsalva Maneuver after Burr Hole Evacuation of Chronic Subdural Hematomas: A Prospective Cohort Study.

Research on chronic subdural hematoma (cSDH) management has primarily focused on potential recurrence after surgical evacuation. Herein, we present a novel postoperative/non-invasive treatment that includes a supervised Valsalva maneuver (SVM), which may serve to reduce SDH recurrence. Accordingly, the aims of the study were to investigate the effects of SVM on SDH recurrence rates and functional outcomes. A prospective study was conducted from December 2016 until December 2019 at the Goethe University Hospital Frankfurt. Of the 204 adult patients with surgically treated cSDH who had subdural drains placed, 94 patients were assigned to the SVM group and 82 patients were assigned to the control group. The SVM was performed by having patients blow into a self-made SVM device at least two times/h for 12 h/day. The primary end-point was SDH recurrence rate, while secondary outcomes were morbidity and functional outcomes at 3 months of follow-up. SDH recurrence was observed in 16 of 94 patients (17%) in the SVM group, which was a significant reduction as compared with the control group, which had 24 of 82 patients (29.3%; p = 0.05) develop recurrent SDHs. Further, the infection rate (e.g., pneumonia) was significantly lower in the SVM group (1.1%) than in the control group (13.4%; p < 0.001; odds ratio [OR] 0.1). At the 3-month follow-up, 85 of 94 patients (90.4%) achieved favorable outcomes in the SVM group compared with 62 of 82 patients (75.6%) in the control group (p = 0.008; OR 3.0). Independent predictors for favorable outcome at follow-up were age (OR 0.9) and infection (OR 0.2). SVM appears to be safe and effective in the post-operative management of cSDHs, reducing both recurrence rates and infections after surgical evacuation, thereby resulting in favorable outcomes at follow-up.

Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage.

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58-1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76-1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.

An association of low high-density lipoprotein levels with recurrence of chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common illness in neurosurgical practice with a substantial recurrence rate. Previous studies found that serum lipids were associated with the risk of stroke and subarachnoid hemorrhage. In the current study, we aimed to identify the relationship between serum lipids and CSDH recurrence. METHODS: The medical records of 274 consecutive surgical patients with CSDH in our department were reviewed and analyzed. Patients were separated into recurrence and non-recurrence groups. Univariable and multivariable Cox proportional hazards regression analyses were performed to identify serum lipids (triglycerides, total cholesterol, LDL, HDL) and other potential predictors associated with CSDH recurrence, and the performance of predictors was assessed with receiver operating characteristic (ROC) curve. RESULTS: Of the 274 patients included in the study, 42 (15.3%) experienced at least 1 recurrence of CSDH. Univariate analysis showed that age, hypertension, diabetes mellitus, anticoagulant use, triglycerides, HDL, and midline shift were all significantly associated with CSDH recurrence. Multivariable Cox regression analysis found that only age, diabetes mellitus, midline shift, and HDL level were independent risk factors for CSDH recurrence. A higher HDL level (HR = 0.929, 95% CI 0.905-0.953) was significantly associated with a lower risk of recurrence, and ROC curve analysis revealed that the optimal HDL cut-off value as a predictor was 37.45 mg/dl. CONCLUSIONS: Low level of high-density lipoprotein is significantly associated with recurrence of chronic subdural hematoma.

Huge chronic subdural haematoma formation in an encephalomalacia stroke cavity.

A patient suffering from a cerebrovascular ischaemic stroke may present similar symptoms to a patient with a chronic subdural haematoma (CSDH). Head CT imaging of an old extensive hemispheric infarction may appear hypodense in a similar fashion as CSDH. We described a 46-year-old man with a 2-week history of mild headache and worsening right lower extremity hemiparesis. Eight years prior, he suffered a left middle cerebral artery territory infarct. The head CT scan showed a huge, slightly hypodense area on the left brain, causing a significant mass effect. A new stroke was of concern versus a chronic subdural haematoma inside the old encephalomalacia stroke cavity. Only three previously reported cases of CSDH occupying an encephalomalacic cavity had been reported. This rare presentation should be considered in the differential diagnosis in patients with a history of cerebrovascular stroke. MRI is useful in making a correct diagnosis.

Lacunar Infarction Caused by Chronic Subdural Hematoma.

In chronic subdural hematoma (CSDH) patients, motor functions usually recover quickly after burr-hole surgery; however, in a rare case, the hemiparesis showed poor improvement after surgery. In that case, investigation of cerebral infarctions is important. Among the 284 CSDH patients with motor weakness, magnetic resonance image (MRI) and MR angiography (MRA) were acquired in 82 patients before surgery when the hemiparesis progressed rapidly. Small lacunar infarction was identified on the hematoma side in five cases; all were older than 80 years with hypertension, and diabetes mellitus had been diagnosed in two. In all the five patients (100%), MRA demonstrated a downward or upward shift of the M1 portion of the middle cerebral artery on the hematoma side, where the perforating arteries originate. Conversely, only 4 CSDH patients (5.2%) without lacunar infarction demonstrated M1 downward shift. The risk factors of lacunar infarction were high in the five detected cases; however, distortion, twisting, or elongation of the lenticulostriate arteries might be a cause of the lacunar infarctions, rather than the formation of lipohyalinosis or microatheroma in the arteries. Therefore, anti-platelet treatment might not be necessary for CSDH-inducing lacunar infarction. The lacunar infarctions caused by CSDH were small, the patients' hemiparesis was mild, a prognosis of all the patients was good, and they recovered well from the motor weakness after physical rehabilitation. MR examinations before surgery are recommended for CSDH patients especially when a patient complains of sudden onset or rapid deterioration of motor weakness.