Tag: chronic subdural hematoma

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Predicting chronic subdural hematoma risk in elderly patients with mild traumatic brain injury

Acta Neurochirurgica (2026) 168:40

This study develops and validates a concise bedside risk score to predict chronic subdural hematoma (CSDH) within 2–12 weeks after mild traumatic brain injury in patients aged 65+. Using a large retrospective cohort (7,246 events) and multivariable modeling, pathological CT at presentation, male sex, older age, and renal failure emerged as key predictors.

The score-based model (including anticoagulant use by expert choice) achieved AUROC 0.76 and 86% sensitivity at the chosen threshold, classifying ~61% as high-risk. Authors propose this tool to guide targeted surveillance and earlier intervention, while noting limitations from retrospective data and need for external validation.

Pathological CT Findings: Pathological findings on initial head CT after mild traumatic brain injury (TBI) are the strongest predictor for developing chronic subdural hematoma (CSDH) within 2–12 weeks in elderly patients.

Key Risk Factors: Older age, male sex, and renal failure are also significant independent predictors for CSDH following mild TBI.

Anticoagulant Use: Chronic use of anticoagulant medications showed a trend toward increased risk but was not statistically significant in this cohort; antiplatelet use was not associated with increased risk.

Prediction Model: A simple score-based risk model was developed, incorporating pathological CT (14 points), male sex (4), renal failure (4), anticoagulant use (4), and age (1 point per 5 years over 65), with a threshold of 5 points or higher identifying high-risk patients.

Model Performance: The risk model achieved an area under the ROC curve (AUROC) of 0.76 and a sensitivity of 86% for detecting CSDH, but the positive predictive value was low (1.6%) due to the rare occurrence of the outcome.

Clinical Implications: Early identification of high-risk patients may enable targeted surveillance, timely CT scanning, and consideration of non-surgical management options such as corticosteroids or middle meningeal artery embolization.

Population Impact: The incidence of CSDH is rising globally due to population aging and increased use of antithrombotic agents, with elderly adults being particularly at risk.

Study Scope: The findings support the use of bedside risk stratification in the emergency department for elderly patients with mild TBI, but further research is needed before widespread clinical implementation.

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Single-Session Middle Meningeal Artery Embolization With Concomitant Evacuation Surgery for Chronic Subdural Hematomas: A Multicenter Assessment of Feasibility, Safety, and Efficacy

Operative Neurosurgery 30:270–277, 2026

This multicenter retrospective cohort assesses feasibility, safety, and short-term efficacy of performing middle meningeal artery embolization (MMAE) concurrently with surgical evacuation for chronic subdural hematoma in a single anesthetic session. Among 157 patients, technical success was 97.4%, radiographic improvement occurred in 91.7%, and 63.1% achieved ≥50% hematoma reduction, with a 10.8% overall complication rate and 0.6% procedure-related mortality.

The report compares outcomes to recent randomized trials and existing series, noting similar intraprocedural complication rates and favorable reintervention and functional-independence outcomes (83.9% mRS ≤2 at median 54 days). Authors highlight potential resource and LOS advantages, acknowledge retrospective limitations, and call for prospective studies to define long-term benefit, cost impact, and selection criteria.

Single-session MMAE plus evacuation: Performing middle meningeal artery embolization (MMAE) and surgical evacuation for chronic subdural hematoma (cSDH) in a single anesthetic session is feasible and technically successful in 97.4% of cases, with no major intraprocedural failures reported.

Safety profile: The overall complication rate for the combined procedure is 10.8%, with a low intraprocedural complication rate of 2.5% and a procedure-related mortality of 0.6%, comparable to or better than staged approaches and recent randomized trials.

Radiographic and functional outcomes: Radiographic improvement is observed in 91.7% of patients, with 63.1% achieving at least a 50% reduction in hematoma thickness; 83.9% of patients maintain or achieve functional independence (mRS ≤2) at short-term follow-up.

Hospital length of stay (LOS): The median hospital LOS is 6 days, which is slightly shorter than reported in comparable studies using staged procedures, suggesting potential for reduced resource utilization.

Reintervention rates: Unplanned reoperations during the index hospitalization are low (2.5%), including for recurrent hematomas and subdural empyema, which favorably compares to other large studies and randomized trials.

Patient selection and anesthesia: Most procedures use general anesthesia (92%), but monitored anesthesia care (MAC) or conscious sedation may further streamline care in selected patients and reduce anesthesia-related risks.

Applicability to complex cases: The single-session approach is effective and safe even in patients with bilateral cSDH, who are often considered more complex.

Future directions: Prospective studies are needed to assess long-term outcomes, cost-effectiveness, ideal patient selection, and whether this approach reduces recurrence and enhances recovery compared to staged strategies.

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Added Value of Adjunctive Middle Meningeal Embolization to Surgical Evacuation for Chronic Subdural Hematoma: Comprehensive Meta-Analysis Based on Controlling Confounders

Neurosurgery 98:303–317, 2026

This meta-analysis evaluates whether adding middle meningeal artery embolization (MMAE) to surgical evacuation improves outcomes in patients with chronic subdural hematoma (CSDH).

Key Insights and Themes

Chronic subdural hematoma (CSDH) is a common neurological disorder with high recurrence rates after surgical evacuation, ranging from 2% to 37%.

Middle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative to surgery, aiming to reduce CSDH recurrence by targeting the vascular supply of the hematoma membranes.

Systematic review and meta-analysis included 17 studies (1814 patients; 939 MMAE+S, 1440 S), comprising randomized trials, matched, and unmatched cohorts, with a mean follow-up of 3 months.

Baseline comparability between MMAE+S and surgery-alone groups was achieved except for higher antithrombotic use in the MMAE+S group (34.9% vs 22.4%).

Recurrence rates were significantly lower in the MMAE+S group compared to surgery alone (4.7% vs 17.7%; relative risk [RR] 0.31, P < .01), a benefit confirmed in randomized and matched studies.

Radiological outcomes (postoperative hematoma thickness, volume, and midline shift) were all significantly reduced in the MMAE+S group.

Functional outcomes, complications, mortality, and hospital stay were similar between groups, indicating no increased risk with adjunctive MMAE.

Timing of embolization affected outcomes: postoperative MMAE was associated with lower recurrence, while preoperative MMAE did not show significant benefit.

Embolic agent selection mattered: liquid embolic agents (e.g., Onyx, Squid) led to better outcomes than particles, with recurrence reduction seen only with liquid agents.

Antithrombotic use, a known risk factor for recurrence, was higher in the MMAE+S group, yet recurrence rates remained lower, suggesting a robust effect of adjunctive MMAE.

Surgical technique variability (burr-hole craniostomy, craniotomy, twist-drill) existed across studies, potentially influencing heterogeneity in outcomes.

Complication rates were low and comparable between groups; most complications were minor, and serious adverse events were rare.

Length of hospital stay did not differ significantly between groups, though some previous studies suggested longer stays with MMAE+S, possibly due to worse initial clinical status.

Cost-effectiveness may favor MMAE+S in the long term, as reduced recurrence and reoperation rates can offset higher initial costs.

Ongoing clinical trials (e.g., CHESS, MEMBRANE, EMPROTECT) are expected to clarify optimal timing, patient selection, and cost-effectiveness of adjunctive MMAE.

Limitations include heterogeneity in surgical and embolization techniques, retrospective study designs, and reliance on aggregate rather than individual patient data.

Areas for future research include optimal timing and materials for MMAE, patient selection, and cost-benefit analyses.

Conclusion

Adjunctive MMAE with surgical evacuation significantly reduces CSDH recurrence and improves radiological outcomes without increasing complications or mortality, supporting its use in high-risk patients.

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Nighttime surgery increases complication risk in chronic subdural hematoma: a population‑based cohort study

Acta Neurochirurgica (2025) 167:311

This population-based retrospective cohort study of 2,860 adults undergoing chronic subdural hematoma (CSDH) evacuation at a tertiary neurosurgical center (2006–2023) examines whether nighttime procedures increase postoperative risk. Nighttime surgery—defined by local shift boundaries—was independently associated with higher moderate-to-severe complications (OR 1.58), with risk peaking during final night-shift hours, while adjusted recurrence differences were not statistically significant.

The paper details standardized surgical protocols, staffing patterns, sensitivity analyses using alternative nighttime definitions, and multivariable models adjusting for comorbidity and neurological status. Authors conclude that when clinical stability permits, deferring CSDH evacuation to daytime hours may reduce significant complications, while acknowledging retrospective limitations and potential residual confounding.

Nighttime surgery: Undergoing chronic subdural hematoma (CSDH) surgery at night is independently associated with a higher risk of moderate-to-severe postoperative complications compared to daytime surgery (OR 1.58; 95% CI 1.04–2.37; p = 0.028).

Complication risk timing: The risk of complications increases gradually overnight and peaks during the final hours of the night shift, suggesting a circadian or fatigue-related effect.

Absolute risk increase: Nighttime surgery results in a 1.6% absolute increase in moderate-to-severe complications, with a number needed to harm (NNH) of 63, indicating a modest but clinically meaningful risk.

CSDH recurrence: Although recurrence rates were higher after nighttime surgery in unadjusted analysis, this difference was not statistically significant after adjusting for confounders (adjusted OR 1.28; 95% CI 0.98–1.65; p = 0.067).

Complication types: The most common moderate-to-severe complications include subdural empyema (1.4%), surgical site infection requiring revision (0.3%), and cerebral herniation (0.3%).

Clinical recommendation: When feasible and the patient is stable, deferring CSDH surgery to daytime hours is advised to minimize complication risk.

Prior research limitations: Previous studies were often underpowered, used inconsistent nighttime definitions, and found mixed results regarding the safety of nighttime CSDH surgery.

Study limitations: Retrospective design, possible unmeasured confounding, small differences in baseline severity, and limited generalizability to other healthcare settings with different resources or scheduling practices.

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Factors affecting outcomes following burr hole drainage of chronic subdural hematoma

J Neurosurg 142:1606–1615, 2025

This large single-center retrospective study of 1226 patients found that preoperative factors—age under 80, independence, higher GCS motor score, fewer medications, and lower ASA grade—predict better outcomes after burr hole drainage for chronic subdural hematoma. Surgical drain use and shorter bed rest improved discharge outcomes, but recurrence was not linked to modifiable factors.

• Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially in elderly patients, and burr hole craniostomy (BHC) is the main surgical treatment.

• This large single-center retrospective study (n=1226) analyzed predictors of outcomes, complications, recurrence, and hospital length of stay (LOS) after BHC for CSDH.

• Favorable short-term outcomes were associated with age <80, preadmission independence, preoperative GCS motor score of 6, fewer than 5 regular medications, and ASA grades I–II.

• Use of a subdural drain and shorter postoperative bed rest (1 day vs 2 days) were linked to better outcomes and higher odds of discharge home.

• No modifiable or nonmodifiable factors, including surgical technique, were significantly associated with CSDH recurrence.

• Polypharmacy (>4 medications) and older age were associated with higher risk of complications and longer hospital LOS.

• Antithrombotic use was not significantly associated with clinical outcomes, recurrence, complications, or LOS.

• Long-term survival was mainly influenced by baseline patient factors (age, independence, GCS-M, ASA grade), not surgical variables.

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Efficacy and safety of tranexamic acid in the management of chronic subdural hematoma

J Neurosurg 141:945–954, 2024

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition, particularly among the elderly. Various treatment options exist, but recurrence rates remain high. This systematic review and meta-analysis aims to assess the efficacy and safety of tranexamic acid (TXA) in the management of CSDH.

METHODS The authors conducted a comprehensive literature search adhering to the 2020 PRISMA guidelines, involving three primary databases (Scopus, PubMed, and Web of Science) that were searched for articles compiled from inception until October 20, 2023. The primary outcome was recurrence of CSDH, and secondary outcomes included complications and SDH volume following TXA treatment. The mean difference and odds ratios with 95% confidence intervals were calculated using the random-effects model.

RESULTS A total of 5 studies, involving 643 patients in the TXA group and 736 patients in the non-TXA group, met the inclusion criteria. The meta-analysis revealed that TXA use led to a significantly lower CSDH recurrence (OR 0.35, 95% CI 0.23–0.53; p < 0.01) without increasing complications (OR 1.84, 95% CI 0.43–7.95; p = 0.42). Additionally, TXA users had a significantly lower CSDH volume compared to the non-TXA group at 3-month follow-up (mean difference −4.56, 95% CI −8.76 to −0.36; p = 0.03).

CONCLUSIONS The findings suggest that TXA might be a promising agent for reducing the risk of CSDH recurrence without elevating the risk of complications. However, these results should be interpreted cautiously due to the limited number of studies included and the methodological heterogeneity. Further large-scale randomized controlled trials are needed to confirm these findings.

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Feasibility, Clinical Potential, and Limitations of Trans-Burr Hole Ultrasound for Postoperative Evaluation of Chronic Subdural Hematoma: A Prospective Pilot Study

Neurosurgery 95:924–931, 2024

Chronic subdural hematoma (CSDH) is commonly managed through burr hole surgery. Routine follow-up using computed tomography (CT) imaging is frequently used at many institutions, contributing to significant radiation exposure. This study evaluates the feasibility, safety, and reliability of trans-burr hole sonography as an alternative postoperative imaging modality, aiming to reduce radiation exposure by decreasing the frequency of CT scans.

METHODS: We conducted a prospective pilot study on 20 patients who underwent burr hole surgery for CSDH. Postoperative imaging included both CT and sonographic examinations through the burr hole. We assessed the ability to measure residual subdural fluid thickness under the burr hole sonographically compared with CT, the occurrence of complications, and the potential factors affecting sonographic image quality. The Pearson correlation coefficient was used to demonstrate relationships between CT and ultrasound and axial and coronal ultrasound.

RESULTS: Sonography through the burr hole was feasible in 73.5% of cases, providing measurements of residual fluid that closely paralleled CT findings, with an average discrepancy of 1.2 mm for axial and 1.4 mm for coronal sonographic views. A strong positive correlation was found between axial and coronal ultrasound (r = 0.955), CT and axial ultrasound (r = 0.936), and CT and coronal ultrasound (r = 0.920). The primary obstacle for sonographic imaging was the presence of air within the burr hole or the subdural space, which typically resolved over time after surgery.

CONCLUSION: Trans-burr hole sonography emerges as a promising technique for postoperative monitoring of CSDH, with the potential to safely reduce reliance on CT scans and associated radiation exposure in selected patients. Our results support further investigation into the extended use of sonography during the follow-up phase. Prospective multicenter studies are recommended to establish the method’s efficacy and to explore strategies for minimizing air presence postsurgery.

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COveRs to impRove EsthetiC ouTcome after Surgery for Chronic subdural hemAtoma by buRr hole trepanation—Results of a Swiss Single-Blinded, Randomized Controlled Trial

Neurosurgery 94:955–965, 2024

Burr hole trepanation to evacuate chronic subdural hematoma (cSDH) results in bony skull defects that can lead to skin depressions. We intend to study the effect of burr hole covers to prevent skin depressions and improve the esthetic result.

METHODS: In a randomized trial, we enrolled adult patients with symptomatic cSDH. Patients received burr hole trepanation with (intervention) vs without burr hole covers (control) in a 1:1 ratio. Patients requiring evacuation of bilateral cSDHs served as their internal control. Primary outcome was satisfaction with the esthetic result of the scar, measured from 0 (dissatisfied) to 10 (very satisfied) on the Esthetic Numeric Analog (ANA) scale at 90 days. Secondary outcomes included ANA scale, rates of skin depression, complications, as well as neurological, disability, and healthrelated quality of life outcomes until 12 months.

RESULTS: We included 78 patients (55 with unilateral and 23 with bilateral cSDH; median age 78 years, 83% male) between 03/2019 and 05/2021, 50 trepanations for the intervention and 51 for the control group. In an intention-to-treat analysis, the ANA scale scores were 9.0 (intervention) and 8.5 (control arm) at 90 days (P = .498). At 12 months, the ANA scale scores were 9.0 and 8.0 for the intervention and control groups, respectively (P = .183). Skin depressions over the frontal burr hole were noted by 35% (intervention) and 63% (control) of patients at 90 days (P = .009) and by 35% and 79% (P < .001) at 12 months, respectively. There were no differences in complications, neurological, disability, and healthrelated quality of life outcomes.

CONCLUSION: Satisfaction with the esthetic result of the scar was inherently high. This study does not show evidence for improvement on the ANA scale by applying a burr hole cover. The application of burr hole covers resulted in less skin depressions and did not negatively affect complication rates or outcomes.

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Automated Preoperative and Postoperative Volume Estimates Risk of Retreatment in Chronic Subdural Hematoma

Neurosurgery 94:317–324, 2024

Several neurosurgical pathologies, ranging from glioblastoma to hemorrhagic stroke, use volume thresholds to guide treatment decisions. For chronic subdural hematoma (cSDH), with a risk of retreatment of 10%–30%, the relationship between preoperative and postoperative cSDH volume and retreatment is not well understood. We investigated the potential link between preoperative and postoperative cSDH volumes and retreatment.

METHODS: We performed a retrospective chart review of patients operated for unilateral cSDH from 4 level 1 trauma centers, February 2009–August 2021. We used a 3-dimensional deep learning, automated segmentation pipeline to calculate preoperative and postoperative cSDH volumes. To identify volume thresholds, we constructed a receiver operating curve with preoperative and postoperative volumes to predict cSDH retreatment rates and selected the threshold with the highest Youden index. Then, we developed a light gradient boosting machine to predict the risk of cSDH recurrence.

RESULTS: We identified 538 patients with unilateral cSDH, of whom 62 (12%) underwent surgical retreatment within 6 months of the index surgery. cSDH retreatment was associated with higher preoperative (122 vs 103 mL; P < .001) and postoperative (62 vs 35 mL; P < .001) volumes. Patients with >140 mL preoperative volume had nearly triple the risk of cSDH recurrence compared with those below 140 mL, while a postoperative volume >46 mL led to an increased risk for retreatment (22% vs 6%; P < .001). On multivariate modeling, our model had an area under the receiver operating curve of 0.76 (95% CI: 0.60-0.93) for predicting retreatment. The most important features were preoperative and postoperative volume, platelet count, and age.

CONCLUSION: Larger preoperative and postoperative cSDH volumes increase the risk of retreatment. Volume thresholds may allow identification of patients at high risk of cSDH retreatment who would benefit from adjunct treatments. Machine learning algorithm can quickly provide accurate estimates of preoperative and postoperative volumes.

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Reducing morbidity associated with subdural drain placement after burr‑hole drainage of unilateral chronic subdural hematomas

Acta Neurochirurgica (2023) 165:3207–3215

Placement of a subdural drain after burr-hole drainage of chronic subdural hematoma (cSDH) significantly reduces risk of its recurrence and lowers mortality at 6 months. Nonetheless, measures to reduce morbidity related to drain placement are rarely addressed in the literature. Toward reducing drain-related morbidity, we compare outcomes achieved by conventional insertion and our proposed modification.

Methods In this retrospective series from two institutions, 362 patients underwent burr-hole drainage of unilateral cSDH with subsequent subdural drain insertion by conventional technique or modified Nelaton catheter (NC) technique. Primary endpoints were iatrogenic brain contusion or new neurological deficit. Secondary endpoints were drain misplacement, indication for computed tomography (CT) scan, re-operation for hematoma recurrence, and favorable Glasgow Outcome Scale (GOS) score (≥ 4) at final follow-up.

Results The 362 patients (63.8% male) in our final analysis included drains inserted in 56 patients by NC and 306 patients by conventional technique. Brain contusions or new neurological deficits occurred significantly less often in the NC (1.8%) than conventional group (10.5%) (P = .041). Compared with the conventional group, the NC group had no drain misplacement (3.6% versus 0%; P = .23) and significantly fewer non-routine CT imaging related to symptoms (36.5% versus 5.4%; P < .001). Re-operation rates and favorable GOS scores were comparable between groups.

Conclusion We propose the NC technique as an easy-to-use measure for accurate drain positioning within the subdural space that may yield meaningful benefits for patients undergoing treatment for cSDH and vulnerable to complication risks.

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Middle Meningeal Artery Embolization in Adjunction to Surgical Evacuation for Treatment of Subdural Hematomas

Neurosurgery 93:1082–1089, 2023

Surgical evacuation is the standard treatment for chronic subdural hematomas (CSDHs) but is associated with a high risk of recurrence and readmission. Middle meningeal artery embolization (MMAE) is a novel treatment approach which could be performed upfront or in adjunction to surgical evacuation. MMAE studies are limited by small sample sizes. This study aimed to describe and compare outcomes of MMAE in adjunction to surgery with those of surgery alone on a national level.

METHODS: The national Vizient Clinical Database was queried by use of a specific validated set of International Classification of Diseases, Tenth Revision codes (October 2018-June 2022). Patients with the diagnosis of nontraumatic CSDH who received MMAE and surgical drainage in the same hospitalization were identified, and their outcomes were compared with isolated surgical drainage.

RESULTS: A total of 606 subjects from 156 institutes and 6340 subjects from 369 institutes were included in the MMAE plus surgery (M&S) and surgery groups, respectively. Average length of stay was significantly longer in the M&S group (9.87 vs 7.53 days; P < .01). There was no significant difference in the in-hospital mortality rate (2.8% vs 2.9%), but the complication rate was significantly higher in the M&S group (8.7% vs 5.5%; P < .01). Complications that were significantly more common in the M&S group included aspiration pneumonia, postoperative sepsis, and anesthesia-related. Mean direct costs were significantly higher in the M&S group (28 834 vs 16 292 US dollars; P < .01). The 30-day readmission rate was significantly lower in the M&S group compared with the surgery group (4.2% vs 8.0%; P < .01).

CONCLUSION: This analysis of large-scale national data indicates that MMAE performed in adjunction to surgery for treatment of CSDH is associated with higher direct costs, higher complication rates, and longer length of stay but lower readmission rates compared with surgical evacuation alone.

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Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

Neurosurgery 92:1142–1154, 2023

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE: To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS: Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS: Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventionalmanagement, respectively.MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR= 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR= 0.78 [0.449-1.25], P= .31), mortality (RR= 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = 0.57 [ 2.55, 1.41], P = .57). ForMMAembolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION: MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

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Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

Neurosurgery 91:842–855, 2022

Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment.

OBJECTIVE: To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH.

METHODS: A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component.

RESULTS: In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36- 0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments.

CONCLUSION: Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.

 

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Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma

Neurosurgery 91:304–311, 2022

The mainstay of treatment for symptomatic or large chronic subdural hematoma (CSDH) is surgery, but controversy still exists regarding the best surgical technique. Three different techniques are commonly used: burr hole craniostomy (BHC), minicraniotomy (MC), and twist drill craniostomy (TDC).

OBJECTIVE: To determine which surgical technique for drainage of CSDH offers best results.

METHODS: We set up a multicenter prospective randomized trial (Comparison of Chronic Subdural Hematoma Treatment [COMPACT] trial) comparing BHC, MC, and TDC for the surgical treatment of CSDH. The primary end point was reoperation rate, and secondary end points included complication rates and clinical outcome. Patients were considered to have good outcome when they did not undergo reoperation, suffered no surgical or medical complication, and had no related mortality. Clinical outcome was also evaluated by evolution of the Markwalder score and the modified Rankin score.

RESULTS: Two-hundred forty-five patients were included in the final analysis: 79 BHC, 84 MC, and 82 TDC. Mean duration of surgery was shorter for TDC than for BHC and MC (P < .001). Reoperation rate was 7.6% for BHC, 13.1% for MC, and 19.5% for TDC (P = .07). This trend toward better results for BHC was not statistically significant in logistic regression analysis. The proportion of patients with good outcome was 78.5% for BHCgroup, 76.2% for MC, and 69.5% for TDC (P = .4). Evolution of the Markwalder score and modified Rankin score were not significantly different between treatment groups.

CONCLUSION: All 3 techniques are effective at treating patients with CSDH with eventual 6-month outcome being similar. Although not reaching statistical significance in our study, BHC offers the lowest recurrence rate combined with manageable complication rate.

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Risk factors of recurrence in chronic subdural hematoma and a proposed extended classification of internal architecture as a predictor of recurrence

Neurosurgical Review (2022) 45:2777–2786

Chronic subdural hematomas (cSDHs) constitute one of the most prevalent intracranial disease entities requiring surgical treatment. Although mostly taking a benign course, recurrence after treatment is common and associated with additional morbidity and costs.

Aim of this study was to develop hematoma-specific characteristics associated with risk of recurrence. All consecutive patients treated for cSDH in a single university hospital between 2015 and 2019 were retrospectively considered for inclusion. Size, volume, and midline shift were noted alongside relevant patient-specific factors. We applied an extended morphological classification system based on internal architecture in CT imaging consisting of eight hematoma subtypes. A logistic regression model was used to assess the classification’s performance on predicting hematoma recurrence.

Recurrence was observed in 122 (32.0%) of 381 included patients. Apart from postoperative depressed brain volume (OR 1.005; 95% CI 1.000 to 1.010; p = 0.048), neither demographic nor factors related to patient comorbidity affected recurrence. The extended hematoma classification was identified as a significant predictor of recurrence (OR 1.518; 95% CI 1.275 to 1.808; p < 0.001). The highest recurrence rates were observed in hematomas of the homogenous (isodense: 41.4%; hypodense: 45.0%) and sedimented (50.0%) types.

Our results support that internal architecture subtypes might represent stages in the natural history of chronic subdural hematoma. Detection and treatment at a later stage of spontaneous repair can result in a reduced risk of recurrence. Based on their high risk of recurrence, we advocate follow-up after treatment of sedimented and homogenous hematomas.

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Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas

Neurosurgery 89:486–495, 2021

Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open- surgical-evacuation-only).

OBJECTIVE: To compare MMA embolization to conventional treatment.

METHODS: Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects.
RESULTS: A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07).

CONCLUSION: There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.

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Risk factors for developing subdural hematoma: a registry-based study in 1457 patients with shunted idiopathic normal pressure hydrocephalus

J Neurosurg 134:668–677, 2021

Subdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH.

METHODS The Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004–2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs.

RESULTS The study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421–3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236–2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups.

CONCLUSIONS iNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.

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Assessment of drainage techniques for evacuation of chronic subdural hematoma

J Neurosurg 133:1113–1119, 2017

Surgery for chronic subdural hematoma (CSDH) is one of the most common neurosurgical procedures. The benefit of postoperative passive subdural drainage compared with no drains has been established, but other drainage techniques are common, and their effectiveness compared with passive subdural drains remains unknown.

METHODS In Scandinavian population-based cohorts the authors conducted a consecutive, parallel cohort study to compare different drainage techniques. The techniques used were continuous irrigation and drainage (CID cohort, n = 166), passive subdural drainage (PD cohort, n = 330), and active subgaleal drainage (AD cohort, n = 764). The primary end point was recurrence in need of reoperation within 6 months of index surgery. Secondary end points were complications, perioperative mortality, and overall survival. The analyses were based on direct regional comparison (i.e., surgical strategy).

RESULTS Recurrence in need of surgery was observed in 18 patients (10.8%) in the CID cohort, in 66 patients (20.0%) in the PD cohort, and in 85 patients (11.1%) in the AD cohort (p < 0.001). Complications were more common in the CID cohort (14.5%) compared with the PD (7.3%) and AD (8.1%) cohorts (p = 0.019). Perioperative mortality rates were similar between cohorts (p = 0.621). There were some differences in baseline and treatment characteristics possibly interfering with the above-mentioned results. However, after adjusting for differences in baseline and treatment characteristics in a regression model, the drainage techniques were still significantly associated with clinical outcome (p < 0.001 for recurrence, p = 0.017 for complications).

CONCLUSIONS Compared with the AD cohort, more recurrences were observed in the PD cohort and more complications in the CID cohort, also after adjustment for differences at baseline. Although the authors cannot exclude unmeasured confounding factors when comparing centers, AD appears superior to the more common PD.

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The Danish Chronic Subdural Hematoma Study—comparison of hematoma age to the radiological appearance at time of diagnosis

Acta Neurochirurgica (2020) 162:2007–2013

Chronic subdural hematomas (CSDH) show different radiological characteristics on CT scans at the time of diagnosis. The reason for this is largely unknown. We hypothesize that the imaging characteristics reflect a time-linked pathophysiological evolution. We therefore conducted a retrospective study to examine a possible relation between the hematoma age and the radiological subtype of a CSDH.

Methods Demographic data on patients with CSDH were retrieved from a Danish national cohort from 2010 to 2012. CT scans obtained on admission to a neurosurgical department were categorized as homogenous, separated, mixed, or membranous hematoma subtypes. The time from a known date of head injury to time of diagnostic CT was defined as hematoma age. The hematoma age was correlated to radiological hematoma subtype at the time of diagnosis by analysis of variance testing.

Results In total, 543 patients were analyzed for hematoma age and classified in the following hematoma subtypes: 231 homogenous, 44 separated, 119 mixed, and 149 membranous. Patients with homogenous, separated, mixed, and membranous hematoma subtypes had a median interval of 37, 36, 40, and 60 days from head injury to diagnostic CT. We found that membranous hematoma is significantly older than other subtypes. Comparison between the other radiological subtypes showed no statistical hematoma age difference. The distribution of radiological subtypes in 590 patients without a known head injury was similar to that of patients with a known head injury. Additionally, we found that hematoma age was significantly younger for patients on antiplatelet medication.

Conclusion In this large national cohort, patients with membranous CSDH had a significantly longer interval between head injury and diagnosis compared to other radiological subtypes. This indicates that the radiological appearance of CSDH evolves over time, causing an alteration from different early radiological subtypes to a radiological subtype with membranes.

Clinical trial registration number The study was approved by the Danish Data Protection Agency (journal no.30-1145).

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