Chronic subdural hematoma recurrence

Chronic subdural hematoma recurrence

Epidemiology

In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care 1).

Recurrence rates after chronic subdural hematoma (CSDH) evacuation with any of actual techniques twist drill craniostomy (TDC), burr hole craniostomy, craniotomy range from 5% to 30%. 2).

Grading

Oslo grading system.

Risk factors

In the series of Santos et al. it was possible to demonstrate an age-related protective factor, analyzed as a continuous variable, regarding the recurrence of the chronic subdural hematoma (CSDH), with a lower rate of recurrence the higher the age.

The results indicate that, among possible factors associated with recurrence, only age presented a protective factor with statistical significance. The fact that no significant difference between the patients submitted to trepanning or craniotomy was found favors the preferential use of burr-hole surgery as a procedure of choice due to its fast and less complex execution 3).

In the series of Han et al. independent risk factors for recurrence were as follows: age > 75 years (HR 1.72, 95% CI 1.03-2.88; p = 0.039), obesity (body mass index ≥ 25.0 kg/m2), and a bilateral operation 4).

Chon et al. shown that postoperative midline shifting (≥5 mm), diabetes mellitus, preoperative seizure, preoperative width of hematoma (≥20 mm), and anticoagulant therapy were independent predictors of the recurrence of chronic subdural hematoma.

According to internal architecture of hematoma, the rate of recurrence was significantly lower in the homogeneous and the trabecular type than the laminar and separated type 5).


The recurrence rate of chronic subdural hematoma cSDH seems to be related to the excessive neoangiogenesis in the parietal membrane, which is mediated via vascular endothelial growth factor (VEGF). This is found to be elevated in the hematoma fluid and is dependent on eicosanoid/prostaglandin and thromboxane synthesis via cyclooxygenase-2 (COX-2).

Anticoagulant therapy

see Chronic subdural hematoma and anticoagulant therapy.

Antiplatelet therapy

Antiplatelet therapy significantly influences the recurrence of CSDH 6).

Pneumocephalus

Remaining pneumocephalus is seen as an approved factor of recurrence 7) 8).

Septation

Jack et al.found a 12% reoperation rate. CSDH septation (seen on computed tomogram scan) was found to be an independent risk factor for recurrence requiring reoperation (p=0.04). Larger post-operative subdural haematoma volume was also significantly associated with requiring a second drainage procedure (p<0.001). Independent risk factors of larger post-operative haematoma volume included septations within a CSDH (p<0.01), increased pre-operative haematoma volume (p<0.01), and a greater amount of parenchymal atrophy (p=0.04). A simple scoring system for quantifying recurrence risk was created and validated based on patient age (< or ≥80 years), haematoma volume (< or ≥160cc), and presence of septations within the subdural collection (yes or no).

Septations within CSDHs are associated with larger post-operative residual haematoma collections requiring repeat drainage. When septations are clearly visible within a CSDH, craniotomy might be more suitable as a primary procedure as it allows greater access to a septated subdural collection. The proposed scoring system combining haematoma volume, age, and presence of septations might be useful in identifying patients at higher risk for recurrence 9).

Membranectomy

Opening the internal hematoma membrane does not alter the rate of patients requiring revision surgery and the number of patients showing a marked residual hematoma six weeks after evacuation of a CSDH 10).

In the study of Lee et al, an extended surgical approach with partial membranectomy has no advantages regarding the rate of reoperation and the outcome. As initial treatment, burr-hole drainage with irrigation of the hematoma cavity and closed-system drainage is recommended. Extended craniotomy with membranectomy is now reserved for instances of acute rebleeding with solid hematoma 11).

Diabetes

Surgeons should consider informing patients with diabetes mellitus that this comorbidity is associated with an increased likelihood of recurrence

12) 13) 14).


Balser et al. report 11% recurrence, which included individuals who recurred as late as 3 years after initial diagnosis 15).

Close imaging follow-up is important for CSDH patients for recurrence prediction. Using quantitative CT volumetric analysis, strong evidence was provided that changes in the residual fluid volume during the ‘self-resolution’ period can be used as significantly radiological predictors of recurrence 16).

A structural equation model showed a significant association between increased antiinflammatory activity in hematoma fluid samples and a lower risk of recurrence, but this relationship was not statistically significant in venous blood samples. Moreover, these findings indicate that anti-inflammatory activities in the hematoma may play a role in the risk of a recurrence of CSDH 17).

Irrigation with artificial cerebrospinal fluid (ACF) decreased the rate of CSDH recurrence 18).

Treatment

There is no definite operative procedure for patients with intractable chronic subdural hematoma (CSDH).

Most recurrent hematomas are managed successfully with burr hole craniostomies with postoperative closed-system drainage. Refractory hematomas may be managed with a variety of techniques, including craniotomy or subdural-peritoneal shunt placement 19).

Although many studies have reported risk factors or treatments in efforts to prevent recurrence, those have focused on single recurrence, and little cumulative data is available to analyze refractory CSDH.

Matsumoto et al. defined refractory CSDH as ≥2 recurrences, then analyzed and compared clinical factors between patients with single recurrence and those with refractory CSDH in a cohort study, to clarify whether patients with refractory CSDH experience different or more risk factors than patients with single recurrence, and whether burr-hole irrigation with closed-system drainage reduces refractory CSDH.

Seventy-five patients had at least one recurrence, with single recurrence in 62 patients and ≥2 recurrences in 13 patients. In comparing clinical characteristics, patients with refractory CSDH were significantly younger (P=0.04) and showed shorter interval to first recurrence (P<0.001). Organized CSDH was also significantly associated with refractory CSDH (P=0.02). Multivariate logistic regression analysis identified first recurrence interval <1 month (OR 6.66, P<0.001) and age <71 years (OR 4.16, P<0.001) as independent risk factors for refractory CSDH. On the other hand, burr-hole irrigation with closed-system drainage did not reduce refractory CSDH.

When patients with risk factors for refractory CSDH experience recurrence, alternative surgical procedures may be considered as the second surgery, because burr-hole irrigation with closed-system drainage did not reduce refractory CSDH 20).

Implantation of a reservoir 21) 22) 23).

Subdural-peritoneal shunt 24).

Middle meningeal artery embolization

Embolization of the MMA is effective for refractory CSDH or CSDH patients with a risk of recurrence, and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution 25) 26) 27) 28) 29) 30).

A pilot study indicated that perioperative middle meningeal artery (MMA) embolization could be offered as the least invasive and most effectual means of treatment for resistant patients of CSDHs with 1 or more recurrences 31).

Chihara et al. have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization 32).

Case series

see Chronic subdural hematoma recurrence case series.

Case reports

Chronic subdural hematoma recurrence case reports.

References

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Escosa Baé M, Wessling H, Salca HC, de Las Heras Echeverría P. Use of twist-drill craniostomy with drain in evacuation of chronic subdural hematomas: independent predictors of recurrence. Acta Neurochir (Wien). 2011 May;153(5):1097-103. doi: 10.1007/s00701-010-0903-3. Epub 2010 Dec 31. PubMed PMID: 21193935.
3)

Santos RGD, Xander PAW, Rodrigues LHDS, Costa GHFD, Veiga JCE, Aguiar GB. Analysis of predisposing factors for chronic subdural hematoma recurrence. Rev Assoc Med Bras (1992). 2019 Jul 22;65(6):834-838. doi: 10.1590/1806-9282.65.6.834. PubMed PMID: 31340313.
4)

Han MH, Ryu JI, Kim CH, Kim JM, Cheong JH, Yi HJ. Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma. J Neurosurg. 2017 Nov;127(5):1117-1125. doi: 10.3171/2016.8.JNS16867. Epub 2016 Dec 16. PubMed PMID: 27982768.
5)

Chon KH, Lee JM, Koh EJ, Choi HY. Independent predictors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien). 2012 Sep;154(9):1541-8. doi: 10.1007/s00701-012-1399-9. Epub 2012 Jun 1. PubMed PMID: 22653496.
6)

Wada M, Yamakami I, Higuchi Y, Tanaka M, Suda S, Ono J, Saeki N. Influence of antiplatelet therapy on postoperative recurrence of chronic subdural hematoma: a multicenter retrospective study in 719 patients. Clin Neurol Neurosurg. 2014 May;120:49-54. doi: 10.1016/j.clineuro.2014.02.007. Epub 2014 Feb 24. PubMed PMID: 24731576.
7)

Mori K, Maeda M (2001) Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371–381
8)

Stanišić M, Hald J, Rasmussen IA, Pripp AH, Ivanović J, Kolstad F, Sundseth J, Züchner M, Lindegaard KF (2013) Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients. Acta Neurochir 155:323–333
9)

Jack A, O’Kelly C, McDougall C, Max Findlay J. Predicting Recurrence after Chronic Subdural Haematoma Drainage. Can J Neurol Sci. 2015 Jan 5:1-6. [Epub ahead of print] PubMed PMID: 25557536.
10)

Unterhofer C, Freyschlag CF, Thomé C, Ortler M. Opening the Internal Hematoma Membrane does not Alter the Recurrence Rate of Chronic Subdural Hematomas – A Prospective Randomized Trial. World Neurosurg. 2016 May 2. pii: S1878-8750(16)30210-8. doi: 10.1016/j.wneu.2016.04.081. [Epub ahead of print] PubMed PMID: 27150644.
11)

Lee JY, Ebel H, Ernestus RI, Klug N. Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol. 2004 Jun;61(6):523-7; discussion 527-8. PubMed PMID: 15165784.
12)

Matsumoto K, Akagi K, Abekura M, Ryujin H, Ohkawa M, Iwasa N, Akiyama C. Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage. Neurol Res. 1999 Apr;21(3):277-80. PubMed PMID: 10319336.
13)

Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H, Endo S. Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model. J Neurosurg. 2003 Jun;98(6):1217-21. PubMed PMID: 12816267.
14)

Pang CH, Lee SE, Kim CH, Kim JE, Kang HS, Park CK, Paek SH, Kim CH, Jahng TA, Kim JW, Kim YH, Kim DG, Chung CK, Jung HW, Yoo H. Acute intracranial bleeding and recurrence after bur hole craniostomy for chronic subdural hematoma. J Neurosurg. 2015 Jul;123(1):65-74. doi: 10.3171/2014.12.JNS141189. Epub 2015 Feb 13. PubMed PMID: 25679282.
15)

Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013 Apr;35(3):233-42. doi: 10.1179/1743132813Y.0000000166. Review. PubMed PMID: 23485050.
16)

Xu FF, Chen JH, Leung GK, Hao SY, Xu L, Hou ZG, Mao X, Shi GZ, Li JS, Liu BY. Quantitative computer tomography analysis of post-operative subdural fluid volume predicts recurrence of chronic subdural haematoma. Brain Inj. 2014;28(8):1121-6. doi: 10.3109/02699052.2014.910702. Epub 2014 May 6. PubMed PMID: 24801643.
17)

Pripp AH, Stanišić M. The Correlation between Pro- and Anti-Inflammatory Cytokines in Chronic Subdural Hematoma Patients Assessed with Factor Analysis. PLoS One. 2014 Feb 27;9(2):e90149. doi: 10.1371/journal.pone.0090149. eCollection 2014. PubMed PMID: 24587250.
18)

Adachi A, Higuchi Y, Fujikawa A, Machida T, Sueyoshi S, Harigaya K, Ono J, Saeki N. Risk factors in chronic subdural hematoma: comparison of irrigation with artificial cerebrospinal fluid and normal saline in a cohort analysis. PLoS One. 2014 Aug 4;9(8):e103703. doi: 10.1371/journal.pone.0103703. eCollection 2014. PubMed PMID: 25089621; PubMed Central PMCID: PMC4121178.
19)

Desai VR, Scranton RA, Britz GW. Management of Recurrent Subdural Hematomas. Neurosurg Clin N Am. 2017 Apr;28(2):279-286. doi: 10.1016/j.nec.2016.11.010. Epub 2017 Jan 4. Review. PubMed PMID: 28325462.
20)

Matsumoto H, Hanayama H, Okada T, Sakurai Y, Minami H, Masuda A, Tominaga S, Miyaji K, Yamaura I, Yoshida Y, Yoshida K. Clinical investigation of refractory chronic subdural hematoma: a comparison of clinical factors between single and repeated recurrences. World Neurosurg. 2017 Aug 24. pii: S1878-8750(17)31402-X. doi: 10.1016/j.wneu.2017.08.101. [Epub ahead of print] PubMed PMID: 28844917.
21)

Sato M, Iwatsuki K, Akiyama C, Masana Y, Yoshimine T, Hayakawa T. [Use of Ommaya CSF reservoir for refractory chronic subdural hematoma]. No Shinkei Geka. 1999 Apr;27(4):323-8. Japanese. PubMed PMID: 10347846.
22)

Sato M, Iwatsuki K, Akiyama C, Kumura E, Yoshimine T. Implantation of a reservoir for refractory chronic subdural hematoma. Neurosurgery. 2001 Jun;48(6):1297-301. PubMed PMID: 11383733.
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Laumer R. Implantation of a reservoir for refractory chronic subdural hematoma. Neurosurgery. 2002 Mar;50(3):672. PubMed PMID: 11841742.
24)

Misra M, Salazar JL, Bloom DM. Subdural-peritoneal shunt: treatment for bilateral chronic subdural hematoma. Surg Neurol. 1996 Oct;46(4):378-83. PubMed PMID: 8876720.
25)

Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. J Neurosurg. 2000 Oct;93(4):686-8. PubMed PMID: 11014549.
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Takahashi K, Muraoka K, Sugiura T, Maeda Y, Mandai S, Gohda Y, Kawauchi M, Matsumoto Y. [Middle meningeal artery embolization for refractory chronic subdural hematoma: 3 case reports]. No Shinkei Geka. 2002 May;30(5):535-9. Japanese. PubMed PMID: 11993178.
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Hirai S, Ono J, Odaki M, Serizawa T, Nagano O. Embolization of the Middle Meningeal Artery for Refractory Chronic Subdural Haematoma. Usefulness for Patients under Anticoagulant Therapy. Interv Neuroradiol. 2004 Dec 24;10 Suppl 2:101-4. Epub 2008 May 15. PubMed PMID: 20587257; PubMed Central PMCID: PMC3522210.
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Tsukamoto Y, Oishi M, Shinbo J, Fujii Y. Transarterial embolisation for refractory bilateral chronic subdural hematomas in a case with dentatorubral-pallidoluysian atrophy. Acta Neurochir (Wien). 2011 May;153(5):1145-7. doi: 10.1007/s00701-010-0891-3. Epub 2010 Dec 2. PubMed PMID: 21125409.
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Mino M, Nishimura S, Hori E, Kohama M, Yonezawa S, Midorikawa H, Kaimori M, Tanaka T, Nishijima M. Efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma. Surg Neurol Int. 2010 Dec 13;1:78. doi: 10.4103/2152-7806.73801. PubMed PMID: 21206540; PubMed Central PMCID: PMC3011107.
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Hashimoto T, Ohashi T, Watanabe D, Koyama S, Namatame H, Izawa H, Haraoka R, Okada H, Ichimasu N, Akimoto J, Haraoka J. Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol Int. 2013 Aug 19;4:104. doi: 10.4103/2152-7806.116679. eCollection 2013. PubMed PMID: 24032079; PubMed Central PMCID: PMC3766342.
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Chihara H, Imamura H, Ogura T, Adachi H, Imai Y, Sakai N. Recurrence of a Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization That Required Craniotomy. NMC Case Rep J. 2014 May 9;1(1):1-5. doi: 10.2176/nmccrj.2013-0343. eCollection 2014 Oct. PubMed PMID: 28663942; PubMed Central PMCID: PMC5364934.

Ossified chronic subdural hematoma

Ossified chronic subdural hematoma

Calcified chronic subdural hematoma or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurological symptoms, is a rarely seen entity that may remain asymptomatic for many years.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years 1).

They should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 2).

Differential diagnosis

Calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis 3).

Treatment

Management of CSDH has improved dramatically in recent years thanks to advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

Systematic reviews

In a systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, 83 patients operated and 31 ones not operated.

There were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean 33.7 years), with etiologies of head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or following cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as X-ray, computed tomography, and magnetic resonance imaging were used with pathological confirmation of CSDH and complete recovery in 56.4% of patients.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years. Therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 4).


Yang X, Qian Z, Qiu Y, Li X. Diagnosis and Management of Ossified Chronic Subdural Hematoma. J Craniofac Surg. 2015 Sep;26(6):e550-1. doi: 10.1097/SCS.0000000000002025. PubMed PMID: 26352368.

Case reports

A 59-year-old man presented with epileptic seizures interpreted as episodic syncope in the past 3 years and the patient had a history of head trauma about 4 years ago. Computed tomography revealed an ossified chronic subdural hematoma involving the right frontotemporoparietal region, which was totally resected using microsurgical technique. Postoperatively, weakness developed in the right arm and magnetic resonance imaging revealed a bilateral tension pneumocephalus, which was immediately treated by a left frontal burr hole trepanation, and the patient was discharged uneventfully 5).


A 46-year-old man with a history of alcohol abuse and a right frontotemporoparietal and left frontal ossified CSH that was diagnosed 2 years previously presented with headache and memory loss over 6 days. The patient was being followed with serial imaging, which showed the static state of the mass and no other lesions 7 months before admission. He underwent right frontotemporoparietal craniectomy to remove the ossified CSH and tumor. When the bone was lifted and the thin dura was opened, a hard, thick, ossified capsule was observed. No apparent tumor invasion was noted in the skull or epidural space. Despite refusing further chemotherapy and radiation therapy, the patient has been disease-free and working for 5 years.

Based on reported cases and relevant literature, large B-cell lymphoma may be associated with ossified CSH 6).


A 81-year-old woman with calcified chronic subdural hematoma. The patient underwent an osteoplastic left craniotomy, evacuation of chronic subdural mass with careful dissection and successful removal of the inner and outer membrane. Postoperative CT scan showed removal of subdural hematoma, a decrease of the left shift of median line and good brain re-expansion. The postoperative period was without any serious complications.

The subdural hematoma was successfully removed, resulting in a good recovery with complete resolution of patient’s symptoms. They highly recommend surgical treatment in cases of chronic symptomatic calcified subdural hematomas 7).


A Giant Ossified Chronic Subdural Hematoma 8).


Fang et al. reported a case of ossified chronic subdural hematoma in a 7-year-old female child, with a literature review 9).


Siddiqui et al. reported one case with diabetes insipidus 10).


A young girl affected by a syndromal hydrocephalus who developed a bilateral ossified chronic subdural hematoma with the typical radiological appearance of “the armored brain”. Bilateral calcified chronic subdural hematoma is a rare complication of ventriculoperitoneal shunt. There is controversy in the treatment, but most published literature discourages a surgical intervention to remove the calcifications 11).


Turgut et al. published one Ossified chronic subdural hematoma 12).


A 22-year-old male who had presented with severe headache consequent to brain compression caused by bifronto-parieto-temporal ossified subdural hematoma. We evaluated our method and surgical intervention in the light of the literature. The question whether the ossified membrane should be excised or not excised in these cases is a matter of controversy. They think that an ossified membrane causing an armored brain appearance should be excised in symptomatic, young patients with prominent cerebral compression. During this dissection, the relatively thickened arachnoid mater provides a safe border 13).


A 67-year-old man presented with headache, dysphasia, and left-sided hemiparesis. Routine skull x-ray showed a huge calcification extending from the frontal to the parietal regions in the right side. CT and MRI scan revealed a huge ossified SDH covering the right hemisphere. Right frontoparietal craniotomy was performed and the ossified SDH was completely removed. Severe adhesion was noticed between the pia mater and the inner surface of the ossified mass. The subdural mass had ossified hard outer and inner rims and a soft central part. The postoperative course was uneventful and 3 months after the operation, the patient was neurologically intact. The authors report the successful treatment of a patient with a huge ossified SDH covering the right hemisphere. Careful dissection and total removal are needed in such symptomatic cases to avoid cortical injury and to improve results 14).


A 24-year-old man with a history of tonic-clonic convulsions since 7 months of age was admitted because of increasing frequency and duration of seizures. Computed tomography and magnetic resonance imaging demonstrated a fusiform extra-axial lesion just above the tentorium and adjacent to the cerebral falx. A calcified and ossified chronic subdural hematoma was noted and was almost completely removed by craniotomy. Better seizure control was achieved by the removal of the calcified chronic subdural hematoma. Calcified subdural hematoma, calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis of an extra-axial calcified lesion 15).


Turgut et al. reported the successful removal of an ossified crust-like chronic subdural hematoma (SDH) covering the hemisphere in a 16-year-old boy. In this article, the importance of the surgical approach is stressed, and the rarity of this condition in the neurosurgical literature is also outlined 16).


A case of ossified chronic subdural hematoma is presented in a 13-year-old male in whom the mass was surgically removed. His neurological deficits continued afterward but were less severe 17).

References

1) , 2) , 4)

Turgut M, Akhaddar A, Turgut AT. Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported during Last Century with a Demonstrative Case Report. World Neurosurg. 2019 Nov 1. pii: S1878-8750(19)32791-3. doi: 10.1016/j.wneu.2019.10.153. [Epub ahead of print] Review. PubMed PMID: 31682989.
3) , 15)

Yan HJ, Lin KE, Lee ST, Tzaan WC. Calcified chronic subdural hematoma: case report. Changgeng Yi Xue Za Zhi. 1998 Dec;21(4):521-5. PubMed PMID: 10074745.
5)

Turgut M, Yay MÖ. A Rare Case of Ossified Chronic Subdural Hematoma Complicated with Tension Pneumocephalus. J Neurol Surg Rep. 2019 Oct;80(4):e44-e45. doi: 10.1055/s-0039-1694738. Epub 2019 Dec 31. PubMed PMID: 31908905; PubMed Central PMCID: PMC6938459.
6)

Liu X, Zhou J, Shen B, Sun D, Zhang Z, Li H, Zhang J. Ossified Chronic Subdural Hematoma and Subsequent Epstein-Barr Virus-Positive Large B-Cell Lymphoma: Case Report and Literature Review. World Neurosurg. 2019 Oct;130:165-169. doi: 10.1016/j.wneu.2019.07.011. Epub 2019 Jul 9. PubMed PMID: 31299306.
7)

Snopko P, Kolarovszki B, Opsenak R, Hanko M, Benco M. Chronic calcified subdural hematoma – case report of a rare diagnosis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2019 Sep 26. doi: 10.5507/bp.2019.041. [Epub ahead of print] PubMed PMID: 31558846.
8)

Tian W, Meng X, Zou J. A Giant Ossified Chronic Subdural Hematoma. J Coll Physicians Surg Pak. 2019 Sep;29(9):905. doi: 10.29271/jcpsp.2019.09.905. PubMed PMID: 31455496.
9)

Fang J, Liu Y, Jiang X. Ossified Chronic Subdural Hematoma in Children: Case Report and Review of Literature. World Neurosurg. 2019 Jun;126:613-615. doi: 10.1016/j.wneu.2019.03.144. Epub 2019 Mar 27. PubMed PMID: 30926556.
10)

Siddiqui SA, Singh PK, Sawarkar D, Singh M, Sharma BS. Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review. World Neurosurg. 2017 Feb;98:520-524. doi: 10.1016/j.wneu.2016.11.031. Epub 2016 Nov 17. Review. PubMed PMID: 27867130.
11)

Viozzi I, van Baarsen K, Grotenhuis A. Armored brain in a young girl with a syndromal hydrocephalus. Acta Neurochir (Wien). 2017 Jan;159(1):81-83. doi: 10.1007/s00701-016-2991-1. Epub 2016 Oct 25. PubMed PMID: 27778104; PubMed Central PMCID: PMC5177664.
12)

Turgut M, Samancoğlu H, Ozsunar Y, Erkuş M. Ossified chronic subdural hematoma. Cent Eur Neurosurg. 2010 Aug;71(3):146-8. doi: 10.1055/s-0030-1253346. Epub 2010 May 3. PubMed PMID: 20440672.
13)

Kaplan M, Akgün B, Seçer HI. Ossified chronic subdural hematoma with armored brain. Turk Neurosurg. 2008 Oct;18(4):420-4. PubMed PMID: 19107693.
14)

Moon HG, Shin HS, Kim TH, Hwang YS, Park SK. Ossified chronic subdural hematoma. Yonsei Med J. 2003 Oct 30;44(5):915-8. PubMed PMID: 14584111.
16)

Turgut M, Palaoğlu S, Sağlam S. Huge ossified crust-like subdural hematoma covering the hemisphere and causing acute signs of increased intracranial pressure. Childs Nerv Syst. 1997 Jul;13(7):415-7. PubMed PMID: 9298279.
17)

Iplikçioğlu AC, Akkaş O, Sungur R. Ossified chronic subdural hematoma: case report. J Trauma. 1991 Feb;31(2):272-5. PubMed PMID: 1994092.

Middle meningeal artery embolization for chronic subdural hematoma systematic reviews

Middle meningeal artery embolization for chronic subdural hematoma systematic reviews

Jumah et al. conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of Middle meningeal artery embolization (MMAE) compared with conventional treatments for refractory or chronic subdural hematoma (cSDH). Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk differences were conducted recurrence, need for surgical rescue, and complications.

Eleven studies (177 patients) were included. The majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. A meta-analysis of proportions showed treatment failure to be 2.8%, the need for surgical rescue 2.7%, and embolization-related complications 1.2%. A meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups.

Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by the paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH 1).


The goal of a study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy. Court et al. performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases. This search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases. MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended 2).


Three double-arm studies comparing embolization and conventional surgery groups and 6 single-arm case series were identified and analyzed. Hematoma recurrence rate was significantly lower in the embolization group compared with conventional treatment group (2.1% vs. 27.7%; odds ratio = 0.087; 95% confidence interval, 0.026-0.292; P < 0.001; I2 = 0%); surgical complication rates were similar between groups (2.1% vs. 4.4%; odds ratio = 0.563; 95% confidence interval, 0.107-2.96; P = 0.497; I2 = 27.5%). Number of patients with modified Rankin Scale score >2 in the embolization (12.5%) versus conventional treatment (9.1%) group showed no statistical difference (P = 0.689). A composite hematoma recurrence rate of 3.6% was found after summing the 6 case series. Composite recurrence and complication rates in the embolization cohorts of the double-arm studies and the case series were lower than literature values for conventional surgical treatments.

MMA embolization is a promising treatment for chronic subdural hematoma. Future randomized clinical trials are needed 3).

References

1)

Jumah F, Osama M, Islim AI, Jumah A, Patra DP, Kosty J, Narayan V, Nanda A, Gupta G, Dossani RH. Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochir (Wien). 2020 Jan 4. doi: 10.1007/s00701-019-04161-3. [Epub ahead of print] Review. PubMed PMID: 31900658.
2)

Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K. Embolization of the Middle meningeal artery in chronic subdural hematoma – A systematic review. Clin Neurol Neurosurg. 2019 Aug 10;186:105464. doi: 10.1016/j.clineuro.2019.105464. [Epub ahead of print] Review. PubMed PMID: 31600604.
3)

Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A, Chen SR, Johnson JN, Kan P. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Meta-Analysis and Systematic Review. World Neurosurg. 2019 Feb;122:613-619. doi: 10.1016/j.wneu.2018.11.167. Epub 2018 Nov 24. PubMed PMID: 30481628.

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