ORIGINAL ARTICLES

SUBDURAL HÆMATOMA: A REVIEW OF 389 CASES

Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood.

An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases.

A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed.

IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

Acute subdural hematoma (SDH) occurs following severe head trauma with brain contusion or rupture of bridging veins. Conversely, SDH caused by rupture of a cortical artery without trauma or with minor trauma is also possible. Although over 180 cases of the latter SDH have been reported, they were predominantly diagnosed only during surgery, and therefore, no adequate histological evaluation has been performed. Therefore, essential etiology of this SDH type has remained unclear. In addition, the scarcity of autopsy cases may be attributed to arterial rupture being missed if the microscopic findings are too minimal to detect during autopsy. Here, we describe two autopsy cases of SDH of cortical artery origin. Extravasation on postmortem computed tomography angiography and arterial leakage on macroscopic observation during autopsy facilitated detection of the ruptured artery and allowed detailed histological evaluation of the ruptured artery and adjacent dura mater. The etiology of arterial rupture is briefly described on the basis of histopathological findings in this study and the available literature.

We describe results of endoscopic surgery for acute subdural hematoma in elderly patients, and simple technique of the endoscopic procedure for acute subdural hematoma (ASDH) through an extended burr hole in elderly patients and discuss its technical aspects.

We performed endoscopic evacuation of acute subdural hematoma in selected fifteen elderly patients. The following data were collected and evaluated: age, sex, laterality, administration of anti-thrombotic agents, injury severity score (ISS), pre and post-operative GCS, modified Rankin scale (mRS) before and post-treatment of ASDH, type of anesthesia, operation time, origin of bleeding.

Postoperatively, satisfactory hematoma evacuation was accomplished. No hemorrhagic adverse effects related with endoscopic procedure were observed. Postoperative GCS was improved in all patients, and three patients were discharged with mRS 0–2 consistent with independent gait.

Endoscopic evacuation of acute subdural hematoma for elderly patient is a less invasive treatment and might be technically feasible in selected cases.

Although the use of a postoperative drain after burr-hole evacuation of chronic subdural hematoma (CSDH) is known to improve surgical outcomes, the superiority of subdural over subperiosteal drains has not been firmly established. Evidence comparing these 2 drain types is largely restricted to single-center series with limited numbers. Using a multicenter cohort study, we aimed to show noninferiority of subperiosteal drains vis-à-vis subdural drains after burr-hole evacuation of CSDH.

We performed a retrospective analysis of all consecutive patients with CSDH aged 21 years and older who had undergone burr-hole craniostomy across 3 tertiary hospitals from 2010 to 2017. Primary outcome measures included CSDH recurrence and modified Rankin Scale (mRS) score at 6 months. Outcomes of patients in the subdural and subperiosteal drain groups were analyzed and confounders were adjusted for using multivariate logistic regression.

Of the 570 cases analyzed, 329 (57.7%) received a subdural drain and 241 (42.3%) received a subperiosteal drain. There was no significant difference between the 2 drain groups in CSDH recurrence (13.1% in the subdural group vs. 11.2% in the subperiosteal group; P = 0.502) or 6-month mRS score (27.2% with mRS 4–6 in the subdural group vs. 20.4% in the subperiosteal group; P = 0.188). Independent predictors of CSDH recurrence identified on multivariate analysis included premorbid mRS score 0–3 (P = 0.021), separated CSDH type on preoperative computed tomography scan (P = 0.002), and postoperative pneumocephalus of ≥15 mm (P = 0.005).

Outcomes of subdural and subperiosteal drains after burr-hole craniostomy for CSDH are largely equivalent based on our findings.

Chronic subdural hematoma is a common neurosurgical disease and the most benign form of intracranial hematoma. Most patients are successfully treated with simple burr hole evacuation and external drainage with good outcome and low rate of complications. Brainstem hemorrhage is a rare cause of severe disability in these patients, and cannot be ignored.

We report the first case of bilateral oculomotor palsy due to a midbrain hemorrhage after evacuation of a unilateral chronic subdural hematoma. The relevant literature is also reviewed to better understand the causes of this rare but disabling occurrence and how it can be prevented during and after surgery.

Neurosurgeons must have awareness of remote intracerebral hemorrhage after burr hole evacuation of chronic subdural hematoma, and take measures to avoid it during surgery. Our experience and the review of the relevant literature demonstrate that preoperative computed tomography can provide information to identify the patients at major risk.

Chronic subdural hematoma is a frequently clinical common problem encountered in neurosurgery practice. Nevertheless, ossified chronic subdural hematoma is extremely rare, especially in children.

Here we report a case of ossified chronic subdural hematoma in a 7-year-old female child, with a literature review.

Because of its infrequency and variable clinical manifestation, ossified chronic subdural hematoma should be considered and included in the differential diagnosis when we encounter an intracranial placeholder.