Refractory chronic subdural hematoma
see also Chronic subdural hematoma recurrence.
Matsumoto et al. defined refractory chronic subdural hematoma 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 1).
HGUA
A 69-year-old male was referred by a subdural hematoma
Past medical history of hypertension, chronic ischemic heart disease
Usual treatment:
ROSUVASTATIN 20 MG
Aspirin 100 MG
OMEPRAZOLE 20 MG
Clopidogrel 75 MG
Viacorlix (perindopril arginine/amlodipine/indapamide)
An extra-axial collection is identified, showing heterogeneous, hyperdense density with a crescent-shaped morphology in the right fronto-parieto-temporal location, with a maximum thickness of 9 mm. Within it, a peripheral semilunar collection of lower attenuation is identified, corresponding to a hematoma, likely in a subacute/chronic evolving phase, with an area of acute rebleeding.
It causes a significant mass effect on the adjacent parenchyma, collapse of the right lateral ventricle (affecting the atrium and the frontal, occipital, and temporal horns), and deviation of midline structures towards the contralateral side (approximately 7mm), consistent with subfalcial herniation.
A hyperdense 3mm-thick lamina is observed in the anterior and posterior interhemispheric fissure and in the cerebellar tentorium, also related to an acute subdural hematoma component.
Right frontotemporal linear incision and frontotemporal craniotomy. Cross-shaped durotomy exposing a well-adhered subdural organized hematoma to the cortex. Evacuation of the hematoma, with cortical re-expansion, which is not complete in the most temporal and posterior part. Irrigation with a saline solution without appreciating active bleeding point. Hemostasis. Primary dural closure. Durapexia at the posterior edge of the craniotomy. Application of epidural Tachosil on the craniotomy edges. Replacement of the cranial bone flap and fixation with Synthes titanium mini plates. Closure of the incision in layers (temporal fascia and subcutaneous tissue with absorbable sutures, and skin with staples).
Postoperative changes of right frontotemporal craniotomy, with increased extracranial soft tissues at that level and presence of mild pneumocephalus in both anterior convexities, predominantly on the right side.
Previously known right subdural collection, with a heterogeneous appearance and currently lower density, which has decreased in size compared to the previous study (current thickness of 9mm in axial view, previously 18mm).
Significant reduction in mass effect on the adjacent parenchyma, with improved visualization of the right hemispheric sulci and partial re-expansion of the ipsilateral lateral ventricle.
Less deviation of the midline, currently measuring 8.5mm (previously 17mm), with mild subfalcine herniation persisting but with resolution of the previously visualized right uncal herniation.
Acute subdural hematoma in the interhemispheric fissure and right tentorium without significant changes compared to the previous study.
No evidence of new extra-axial hemorrhages or presence of intra-axial bleeding.
Clinical deterioration
Radiological worsening with increased mass effect on the adjacent parenchyma, causing a widespread effacement of the right hemispheric sulci and the near-complete collapse of the occipital and temporal horns, and partial collapse of the frontal horn of the right lateral ventricle, with a midline deviation of approximately 12mm (previously 6mm), along with increased right subfalcine and uncal herniation, compressing the ipsilateral cerebral peduncle.
The previous craniotomy is extended anteriorly to the pterion, exposing the cranial base. A cross-shaped durotomy is performed (previous dural opening at the center of the current craniotomy) with drainage of acute subdural hematoma. The relaxed cerebral cortex with partial re-expansion is observed. All visible hematoma is evacuated down to the anterior cranial base and middle fossa. Hemostasis is achieved. Subdural and epidural Espongostan is placed (dural closure not performed due to the inability to properly approximate the edges). The bone flap is replaced using 0 silk sutures (a portion of the bone from the previous surgery is fixed to the current craniotomy using the same DePuy Sinthex plates from the previous surgery). The incision is closed in layers (muscle with 0 Vicryl, subcutaneous tissue with 2/0 Vicryl, and skin with staples).
