Chronic subdural hematoma
Latest chronic subdural hematoma PubMed Related Articles
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Definition
Chronic subdural hematoma (CSDH) is an encapsulated collection of old blood, mostly or totally liquefied and located between the dura mater and the arachnoid mater.
They are arbitrarily defined as those hematomas presenting 21 days or more after injury. These numbers are not absolute, and a more accurate subdural hematoma classification usually is based on imaging characteristics.
History
COVID-19 in chronic subdural hematoma
Epidemiology
Etiology
Chemokines in Chronic Subdural Hematoma
Classification
Pathophysiology
Pathology
cSDHs have a tendency to persist and gradually increase in volume over time. The disease is thought to be related to a cycle of chronic inflammation and angiogenesis. An original hemorrhage forms and fibrinolysis ensues with the liquefaction of the initial clot. The subsequent blood breakdown products stimulate inflammation and thickening of the inner dural layer (ie, ‘dural border cells). This process incites angiogenesis with the ingrowth of immature capillaries, which chronically leak blood. These microhemorrhages result in the progressive enlargement of the collection with increased fibrinolytic activity, inflammation, and further angiogenesis, membrane formation, and vessel proliferation. The rate of accumulation of blood products outpaces physiological reabsorption and the collection gradually enlarges. Thus the entire basis for the pathology is the formation of leaky vascular membranes, which incite a positive feedback cycle of continued hemorrhage, inflammation, and angiogenesis 1) 2)
Chronic subdural hematoma (CSDH) is characterized by an “old” encapsulated collection of blood and blood breakdown products between the brain and its outermost covering (the dura).
It is delimited by an outer and inner membrane. In between are blood, plasma, cerebrospinal fluid, membranes, and a mixture of inflammatory angiogenic fibrinolytic and coagulation factors. These factors maintain a self-perpetuating cycle of bleeding, lysis, and growing of neo-membranes and neo-capillaries 3).
Clinical Features
Scales
Diagnosis
Biomarkers
The association between the biomarkers of inflammation and angiogenesis, and the clinical and radiological characteristics of CSDH patients, need further investigation. The high number of biomarkers compared to the number of observations, the correlation between biomarkers, missing data and skewed distributions may limit the usefulness of classical statistical methods.
Pripp et al. explored lasso regression to assess the association between 30 biomarkers of inflammation and angiogenesis at the site of lesions, and selected clinical and radiological characteristics in a cohort of 93 patients. Lasso regression performs both variable selection and regularization to improve the predictive accuracy and interpretability of the statistical model. The results from the lasso regression showed analysis exhibited lack of robust statistical association between the biomarkers in hematoma fluid with age, gender, brain infarct, neurological deficiencies and volume of hematoma. However, there were associations between several of the biomarkers with postoperative recurrence requiring reoperation. The statistical analysis with lasso regression supported previous findings that the immunological characteristics of CSDH are local. The relationship between biomarkers, the radiological appearance of lesions and recurrence requiring reoperation have been inclusive using classical statistical methods on these data, but lasso regression revealed an association with inflammatory and angiogenic biomarkers in hematoma fluid. They suggest that lasso regression should be a recommended statistical method in research on biological processes in CSDH patients 4).
Differential diagnosis
Chronic subdural hematoma (CSDH) is a disease of the meninges and is to be distinguished from hygroma and subdural empyema.
Subdural effusion in the setting of dural metastases is very rare and may be difficult to be distinguished from chronic subdural hematoma. Such lesions could be missed and could be the cause of recurrence in CSDH. A contrast-enhanced brain CT scan is recommended to diagnose dural metastases.
Rosai–Dorfman disease may be mistaken for a CSDH on imaging. This disease is an uncommon, benign systemic histioproliferative disease characterized by massive lymphadenopathy, particularly in the head and neck region, and is often associated with extranodal involvement. CSDH can also develop in multifocal fibrosclerosis (MFS) which is a rare disorder of unknown etiology, characterized by chronic inflammation with dense fibrosis and lymphoplasmacytic infiltration into the connective tissue of various organs. The mechanism of the formation of CSDH is presumed to involve reactive granular membrane together with subdural collection. On the other hand, the extramedullary erythropoiesis within CSDH can be confused with metastatic malignant tumors, such as lymphoma, carcinoma, and malignant melanoma 5).
A 44-year old woman with gastric adenocarcinoma was presented with headache and a hypodense subdural collection in right fronto-parietal in brain CT. Burr-hole irrigation was performed with the impression of chronic subdural hematoma, but nonhemorrhagic xantochromic fluid was evacuated without malignant cell. Brain CT on the 11th day depicted fluid re-accumulation and noticeable midline shift, necessitating craniotomy and removing the affected dura.
Because the affected dura can be supposed as the main source of subdural effusion, resection of the involved dura is obligatory for the appropriate palliative management of such patients 6).
Guidelines
Stubbs et al. outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents 7)
Treatment
Prognosis
Complications
The progression of CSDH is an angiogenic process, involving inflammatory mediators that affect vascular permeability, microvascular leakage, and hematoma thickness.
Recurrence
Systematic Reviews
Bibliometrics
A bibliometrics retrieved 1424 CSDH-related articles published since the beginning of the twenty-first century. There was a general increase in both the number of published articles and the mean number of citations. The authors, institutions, and journals that contributed the most to the field of CSDH were Jianning Zhang, Tianjin Medical University General Hospital, and world neurosurgery, respectively. The reference co-citation network identified 13 clusters with significant modularity Q scores and silhouette scores (Q = 0.7124, S = 0.8536). The major research categories were (1) the evolution of the therapeutic method and (2) the etiology and pathology of CSDH. Keyword analysis revealed that 'middle meningeal artery embolization' was the latest burst keyword.
This study identified the most influential countries, authors, institutions, and journals contributing to CSDH research and discussed the hotspots and the latest subjects of CSDH research 8)
Feasibility studies
Cardoso et al. investigated the feasibility of combining the surgical obliteration of the MMA at the same time as the placement of a burr hole for evacuation of the CSH.
They report on nine patients who underwent 11 of these combined procedure by the same surgeon in two hospitals, including clinical data and images during the perioperative and postoperative periods. Cardoso had previously reported details of the surgical technique. Two patients underwent bilateral procedures. Two patients had two burr holes because the hematomas did not extend caudally to the pterion, where the MMA enters the calvarium. Intraoperative fluoroscopy was used to locate the point of entry of the MMA into the calvarium in most cases, except in two instances when navigation was utilized.
This small series of nine cases suggests the feasibility of using this combined procedure as an additional option to the treatment of CSHs, especially where endovascular treatment might not be readily available. Furthermore, it has the potential advantages of safety, efficacy, avoidance of a second endovascular procedure, faster disappearance of the subdural collection, lesser exposure to radiation, and cost containment. Larger prospective controlled series are needed to identify its potential usefulness 9).
Retrospective comparative studies
A retrospective comparative study was conducted utilizing the data of 60 patients operated for symptomatic CSDH. Patients were divided into two groups, each thirty consecutive patients: Group I, in which a SGD was inserted after CSDH evacuation through a burr-hole; and Group II, the hematoma was evacuated as in the Group I, but with no SGD insertion but instead a subgaleal pocket was created for drainage.
The neurological improvement at 24 h, discharge, 2 weeks, and 6 months after surgery was comparable in both groups. The overall recurrence was 4 cases (4/60, 6.7%). The rate of recurrence and surgical infection rate were comparable in both groups. Both groups showed similar incidences of postoperative seizures, bleeding, rates of medical complications, and neurological deficits. The overall postoperative mortality was five cases (5/60, 8.3%) with no significant difference between groups.
Blunt dissection to open the subgaleal space and closure without a drain is a safe and efficient alternative to the insertion of a drain after the burr-hole evacuation of CSDH 10).
Havryliv et al. conducted a retrospective study of 67 consecutive patients who had 74 procedures for CSDH in a single neurosurgical center, the Regional Clinic, Centre of Neurosurgery and Neurology, over a 3-year period. They were grouped into the GA group (n = 44) and LA group (n = 23). Mean duration of procedure, length of hospital stay, complications, and preoperative and postoperative neurologic statuses were compared. The distribution of nominal variables between groups was compared using the Fisher exact test. The average duration of operation and length of hospital stay were compared using the Mann-Whitney U-test due to violation of the normality assumption.
LA proved to be as effective as GA in CSDH evacuation. Seventy-four surgical procedures were performed on 67 patients due to recurrence in less than 30 days in 7 patients. Fifteen patients had tension pneumocephalus managed with fluid therapy to full recovery. LA was economical and required shorter hospital stays and surgical time.
LA proved to be noninferior to GA, time conserving, and less prone to some of the adverse effects of GA on elderly patients with comorbidity, although some patients who are hyperactive or contraindicated to LA will require GA 11).
Case series
Case reports
Research
Trials
A prospective, multicenter, open-label, blinded endpoint randomized controlled trial designed to include 304 participants over the age of 18-90 years presenting with a symptomatic CSDH verified on cranial computed tomography or magnetic resonance imaging. Participants will be randomly allocated to perform exhaustive drainage (treatment group) or fixed-time drainage (control group) after a one-burr hole craniostomy. The primary endpoint will be recurrence indicating a reoperation within 6 months.
This study will validate the effect and safety of exhaustive drainage after one-burr hole craniostomy in reducing recurrence rates and provide critical information to improve CSDH surgical management.
Trial registration: Clinicaltrials.gov, NCT04573387. Registered on October 5, 2020 12).
Experimental models
Attempts to create CSDH have been made in mice, rats, cats, dogs and monkeys. Methods include injection or surgical implantation of clotted blood or various other blood products and mixtures into the potential subdural space or the subcutaneous space. No intracranial model produced a progressively expanding CSDH. Transient hematoma expansion with liquification could be produced by subcutaneous injections in some models. Spontaneous subdural blood collections were found after creation of hydrocephalus in mice by systemic injection of the neurotoxin, 6-aminonicotinamide. The histology of the hematoma membranes in several models resembles the appearance in humans. None of the models has been replicated since its first description.
D'Abbondanza et al. did not find a report of a reproducible, well-described animal model of human CSDH 13).
Retracted articles
Zhuang Y, Jiang M, Zhou J, Liu J, Fang Z, Chen Z. Surgical Treatment of Bilateral Chronic Subdural Hematoma. Comput Intell Neurosci. 2022 Jun 27;2022:2823314. doi: 10.1155/2022/2823314. Retraction in: Comput Intell Neurosci. 2022 Dec 25;2022:9806807. PMID: 35795746; PMCID: PMC9252673.
Case reports from the HGUA
A 98-year-old male patient with a history of hypertension, atrial fibrillation, and congestive heart failure presented with a known diagnosis of Parkinson's disease, which had been established more than 15 years ago. The patient's daughter reported that the clinical symptoms began with dizziness and tremors in the upper limbs, which had remained stable up to the current presentation. Despite his age, the patient was independent in activities of daily living until a few months ago when he experienced a recent episode of tremors, decreased strength, and coordination difficulties. Additionally, he had trouble sleeping, with only a few hours of fragmented sleep.
Diagnostic Imaging: A non-contrast CT scan of the head was performed on June 22, 2023, following the recent episode. The imaging revealed the following findings:
Report: There was a right frontoparietotemporal extraaxial collection with subdural morphology, measuring approximately 15 mm in the coronal plane and in its most anterior portion. The density of the collection was iso/hypodense compared to the brain parenchyma. Additionally, there were slightly more hyperdense foci within the collection, suggesting a probable subacute subdural hematoma with signs of recent bleeding. On the contralateral convexity, a smaller extraaxial collection with similar characteristics (approximately 9-10 mm in maximum thickness in the posterior region) was also identified, indicative of a subacute subdural hematoma with recent bleeding. While both collections exerted a mild mass effect on the underlying sulci, the midline remained centered, and the basal cisterns were not occupied.
No definite signs of intracerebral bleeding were identified. The ventricular system and sulci were age-appropriate.
Conclusion: This case describes a 98-year-old male patient with Parkinson's disease who presented with a recent episode of tremors, decreased strength, and coordination difficulties. The CT scan revealed bilateral subacute subdural hematomas with signs of recent bleeding. Prompt recognition and appropriate management of such complications in elderly patients with neurodegenerative disorders are crucial to prevent further neurological deterioration and optimize patient outcomes. Clinicians should maintain a high index of suspicion for subdural hematomas in elderly patients with neurologic comorbidities. Regular follow-up and monitoring are necessary to assess the progression of the hematomas and tailor interventions accordingly.