Chronic subdural hematoma recurrence case reports

• The drainage tube into the dural-outer membrane space during burr hole evacuation for chronic subdural hematoma: Novel case report of 2 patients
• Endoscopic subdural membranectomy for multi-septated chronic subdural hematoma: Finding a safe solution when middle meningeal artery embolization is not feasible
• Gliomagenesis following chronic subdural hematoma: A case report
• Meningioma growth beneath the outer membrane of a traumatic chronic subdural hematoma after burr-hole drainage: a case report and literature review
• Incision of the Internal Membrane Under an Endoscope for Advanced Organized Chronic Subdural Hematoma: A Case Report
• Brain sagging syndrome: Occult cerebrospinal fluid leakage as a cause of failed brain expansion after removal of bilateral chronic subdural hematomas
• Middle Meningeal Artery (MMA) Embolization for Recurrent Subacute Subdural Hematoma With Complete Resolution Following Transient Radiological Size Progression: A Case Report and Literature Review
• 2024 middle meningeal artery embolization trials: A comprehensive review of past, recent, and ongoing trials

In a case report Lili Chen *et al.* from the Neurology Dept, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou Guangyu Ying *et al.*, Yucong Peng *et al.*; Neurosurgery Dept, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou published in the Clinical Case Reports Journal to highlight spontaneous intracranial hypotension (SIH) as a diagnostic pitfall in recurrent subdural hematoma (SDH) and to demonstrate the efficacy of targeted epidural blood patch (EBP) prior to surgical drainage. In non‑elderly patients with SDH and no trauma or obvious risk factors, SIH should be suspected. A targeted EBP may resolve the CSF leak and prevent recurrence, possibly avoiding or supplementing surgical intervention ¹⁾.

The case underscores an underrecognized etiology (SIH) in SDH, offering a valuable shift in differential diagnosis.

- Novelty: It adds to limited case literature by emphasizing targeted EBP efficacy specifically in recurrent SDH associated with SIH.

- Limitations:

1. As a single case, generalizability is restricted.  

2. Details on imaging (e.g., leak localization via CT myelography) and follow‑up duration are sparse.  

3. No comparison with conservative management or surgical-only outcomes.  

- Methodological rigor:

Standard diagnostic and therapeutic steps were applied, but the narrative lacks clarity on decision‑making timeline and objective measures of improvement.

- Interpretation:

The authors convincingly argue for EBP before surgery, though this remains hypothesis‑forming given the lack of broader data.

Verdict

Score: 6.5 / 10

Good clinical insight with moderate impact, yet limited by its single-case design and lack of comprehensive imaging/follow-up details.

Evaluate SIH in recurrent SDH patients without trauma—employ CT myelography to localize leaks and consider targeted EBP early. This may reduce recurrence and the need for multiple surgical evacuations.

In select cases of spontaneous recurrent SDH, targeted EBP can be an effective, minimally invasive first-line treatment. Further studies are needed to confirm broader efficacy.

Category: Case Report, Neurosurgery

Tags: spontaneous intracranial hypotension, subdural hematoma, epidural blood patch, CT myelography, diagnostic pitfall

Mewada et al. report a case with right hemiparesis and aphasia 1 month after a fall from a bicycle. Computed tomography scan of the head showed left chronic subdural hematoma, which was evacuated by burr-hole drainage. The postoperative course was complicated by reaccumulation within short period of time. On superselective digital subtraction angiography of MMA, iatrogenic dAVF was found on left side. We embolized successfully it using n-butyl cyanoacrylate after a third irrigation. No reaccumulation found in the postoperative period or at last follow-up. They proposed a treatment protocol based on the own experience and literature review.

Refractory chronic subdural hematoma with reaccumulation within a short interval should be subjected to digital subtraction angiography of the MMA. Embolization of ipsilateral MMA is safe, effective, and a useful option for the treatment of iatrogenic dAVF and resolution of hematoma ²⁾.

An 85-year-old male presented with left CSDH, which recurred five times. The hematoma was irrigated and drained through a left frontal burr hole during the first to third surgery and through a left parietal burr hole during the fourth and fifth surgery. The hematoma had no septation and was well-evacuated during each surgery. Antiplatelet therapy for preventing ischemic heart disease was stopped after the second surgery, the hematoma cavity was irrigated with artificial cerebrospinal fluid at the third surgery, and the direction of the drainage tube was changed to reduce the postoperative subdural air collection at the fourth surgery. However, none of these interventions was effective. He was successfully treated by fibrin glue injection into the hematoma cavity after the fifth surgery.

This procedure may be effective for refractory CSDH in elderly patients ³⁾.

A 67-year-old man with dural arteriovenous fistula (AVF) presenting as a non-traumatic chronic subdural hematoma (CSDH). This previously healthy patient was hospitalized due to progressive headache with subacute onset. He underwent burr-hole surgery twice for evacuating the left CSDH that was thickest at the posterior temporal area. The operative procedure and finding was not extraordinary, but subdural hematoma slowly progressed for days following the revision surgery. After investigation by super-selective external carotid angiography, a dural AVF found near the transverse-sigmoid sinus was diagnosed. Dural AVF was completely occluded with trans-arterial injecting polyvinyl alchol particles into the petrosquamosal branch of the middle meningeal artery. The patient showed a good neurological outcome with no additional intervention. Brain surgeons have to consider the possibility of dural AVF and perform cerebral angiogram if necessary when they manage the cases that have a spontaneously occurred and repeatedly recurring CSDH ⁴⁾.

Spontaneous intracranial hypotension (SIH) is reported to cause chronic subdural hematoma (SDH), however diagnosis of SIH in patients with SDH is not always easy.

Takahashi et al. report a case of chronic SDH refractory to repeated drainage, which was attributed to SIH. A forty-five-year-old man who had been suffering from orthostatic headache for one month was admitted to our hospital presenting with unconsciousness and hemiparesis. CT on admission revealed a chronic subdural hematoma, which was successfully treated once with subdural drainage. However, the patient fell into unconscious again with recurrence of the hematoma within several days. After two more sessions of drainage, SIH due to cerebrospinal fluid leakage was diagnosed with spinal magnetic resonance imaging (MRI) and radionuclide cisternography. Spinal MRI demonstrated abnormal fluid accumulation in the thoracic epidural space, and the radionuclide cisternogram showed early excretion of tracer into urine as well as absence of intracranial tracer filling. After treatment with epidural blood patching, the hematoma rapidly disappeared and he was discharged without symptoms. In the treatment of chronic SDH, especially in young to middle aged patient without preceding trauma or hematological disorders, physicians should pay attention to underlying SIH to avoid multiple surgery. MRI of the spine as well as radionuclide cisternography is useful in evaluation of this condition ⁵⁾.