• Journal of Korean Neurosurgical Society
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• v.54 no.1
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• pp.38-41
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• 2013

Objective : Density of the chronic subdural hematoma (cSDH) is variable. It often appears to be mixed density. Multiple densities of cSDH may result from multiple episodes of trauma. We investigated the frequency of mixed density and the causes of head injuries representing each density. Methods : We could collect 242 cases of chronic SDH. The cSDHs were classified into four groups; hypodensity, homogeneous isodensity, layered type, and mixed type on the basis of CT scans. Results : The density of cSDH was isodense in 115 patients, hypodense in 31 patients, mixed in 79 cases, and layered in 17 cases. The cSDH was on the left side in 115 patients, on the right side in 70 patients, and bilateral in 40 patients. The history of trauma was identifiable in 122 patients. The etiology could be identified in 67.7% of the hypodense hematomas, while it was obscure in 59.5% of the mixed hematomas. Conclusion : Mixed density of cSDH results from multiple episodes of trauma, usually in the aged. It is hard to remember all the trivial traumas for the patients with the mixed density cSDHs. Although there were membranes within the mixed density hematomas, burr-holes were usually enough to drain the hematomas.

• Journal of Korean Neurosurgical Society
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• v.52 no.3
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• pp.234-239
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• 2012

Objective : Chronic subdural hematoma (CSDH) is a typical disease that is encountered frequently in neurosurgical practice. The medications which could cause coagulopathies were known as one of the risk factors of CSDH, such as anticoagulants (ACs) and antiplatelet agents (APs). Recently, the number of patients who are treated with ACs/APs is increasing, especially in the elderly population. With widespread use of these drugs, there is a need to study the changes in risk factors of CSDH patients. Methods : We retrospectively reviewed 290 CSDH patients who underwent surgery at our institute between 1996 and 2010. We classified them into three groups according to the time of presentation (Group A : the remote period group, 1996-2000, Group B : the past period group, 2001-2005, and Group C : the recent period group, 2006-2010). Also, we performed the comparative analysis of independent risk factors between three groups. Results : Among the 290 patients, Group A included 71 patients (24.5%), Group B included 98 patients (33.8%) and Group C included 121 patients (41.7%). Three patients (4.2%) in Group A had a history of receiving ACs/APs, 8 patients (8.2%) in Group B, and 19 patients (15.7%) in Group C. Other factors such as head trauma, alcoholism, epilepsy, previous neurosurgery and underlying disease having bleeding tendency were also evaluated. In ACs/APs related cause of CSDH in Group C, significantly less proportion of the patients are associated with trauma or alcohol compared to the non-medication group. Conclusion : In this study, the authors concluded that ACs/APs have more importance as a risk factor of CSDH in the recent period compared to the past. Therefore, doctors should prescribe these medications carefully balancing the potential risk and benefit.

• Journal of Korean Neurosurgical Society
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• v.52 no.2
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• pp.133-137
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• 2012

Objective : Twist-drill craniostomy (TDC) with closed-system drainage and burr-hole drainage (BHD) with a closed system are effective treatment options for chronic subdural hematoma (CSDH). The aim of this study was to analyze clinical data and surgical results from symptomatic CSDH patients who underwent TDC with closed-system drainage at the pre-coronal point (PCP). Methods : We analyzed data for 134 symptomatic CSDH patients who underwent TDC at the PCP with closed-system drainage. We defined the PCP for TDC to be 1 cm anterior to the coronal suture at the level of superior temporal line. TDC at the PCP with closed-system drainage was selected in patients with CSDH that extended beyond the coronal suture, confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed retrospectively. Results : Of the 134 CSDH patients, 114 (85.1%) showed improved clinical performance and imaging findings after surgery. Catheter failures were seen in two cases (1.4%); the catheters were inserted in the epidural space. Recurrent cases were seen in eight patients (5.6%), and they were improved with a second BHD with a closed-system operation. Conclusion : TDC at the PCP with closed-system drainage is safe and effective for patients with symptomatic CSDH whose hematomas extend beyond the coronal suture.

• Journal of Trauma and Injury
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• v.33 no.2
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• pp.81-87
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• 2020

Purpose: Chronic subdural hematoma (CSDH) is a common disease in elderly patients and is usually treated by burr-hole drainage. However, the optimal surgical technique for treating CSDH has not been determined. In this study, we analyzed outcomes and recurrence rates after burr-hole drainage with or without irrigation in patients with CSDH. Methods: Eighty-two CSDH patients treated with burr-hole drainage at Wonju Severance Christian Hospital from March 2015 to June 2016 were enrolled in this study. The subjects were divided into three groups based on the surgical technique performed as follows: single burr-hole drainage without irrigation (group A, n=47), single burr-hole drainage with irrigation (group B, n=14), or double burr-hole drainage with irrigation (group C, n=21). These three groups were compared with respect to clinical and radiological factors and the recurrence rate, and independent factors predicting recurrence were sought. Results: After burr-hole drainage, CSDH recurred in 15 (18.3%) of the 82 patients, and six patients (7.3%) required reoperation. More specifically, recurrence was observed in 12 patients (25.5%) in group A, one (7.1%) in group B, and two (9.5%) in group C. The number of burr-holes did not significantly affect recurrence (odds ratio [OR]=0.38; 95% confidence interval [CI]: 0.60-2.38), but irrigation had a significant effect (OR=0.20; 95% CI: 0.04-0.97). Conclusions: This study shows that irrigation during burr-hole surgery in CSDH patients significantly reduced the risk of recurrence, regardless of the number of burr-holes used. We therefore recommend the use of active irrigation during burr-hole drainage surgery in CSDH patients.

• Journal of Korean Neurosurgical Society
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• v.63 no.4
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• pp.455-462
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• 2020

Objective : Recent studies have reported that arachnoid plasty (ARP) using gelatin sponges with fibrin glue reduced the occurrence of chronic subdural hematoma (CSDH) following clipping surgery for unruptured intracranial aneurysm (UIA). This meta-analysis was conducted to collate further evidence for the efficacy of ARP in preventing postoperative CSDH. Methods : Data of patients who underwent clipping surgery were extracted from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials by two independent reviewers. A random effects model was used to investigate the efficacy of ARP by using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for male sex was additionally preformed. Results : Data from six studies with 1715 patients were consecutively included. Meta-analysis revealed that ARP was significantly associated with lower rates of CSDH development after surgical clipping for UIA (ARP group vs. control group : 3.2% vs. 7.2%; OR, 0.40; 95% CI, 0.18-0.93; I²=44.3%; p=0.110). Meta-regression analysis did not highlight any modifying effect of the male sex on postoperative CSDH development (p=0.951). Conclusion : This meta-analysis indicated that ARP reduced the incidence rates of CSDH following clipping surgery for UIA. If feasible, ARP would be implemented as an additional surgical technique to prevent postoperative CSDH development during surgical clipping of UIA.

• Journal of Korean Neurosurgical Society
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• v.63 no.4
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• pp.513-518
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• 2020

Objective : Chronic subdural hematoma (CSDH) is one of the most common intracranial hemorrhages. It can be managed with a simple surgical treatment such as burr-hole trephination and drainage. However, it has a relatively high recurrence rate. The mechanisms and risk factors for the recurrence have not yet been clearly identified and studies have reported varying results. Methods : We analyzed 230 patients with CSDH who were treated with burr-hole trephination and drainage at our institution from March 2011 to March 2016. The patients were divided into recurrence and non-recurrence groups and the medical records of each group were used to analyze the risk factors associated with CSDH recurrence. Results : After burr-hole trephination and drainage, CSDH recurrence was observed in 49 (21.3%) of the 230 patients. In univariate analysis, none of the factors showed statistical significance with respect to CSDH recurrence. In multivariate analysis, preoperative antithrombotic medication was the only independent risk factor for CSDH recurrence (odds ratio, 2.407; 95% confidence interval, 1.047-5.531). Conclusion : The present study found that preoperative antithrombotic medication was independently associated with CSDH recurrence.

• Journal of Korean Neurosurgical Society
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• v.29 no.6
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• pp.748-753
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• 2000

Objectives : A 10-year retrospective clinical study was undertaken to determine the differences between two groups according to age at presentation(group A, under 50 ; B, over 50). Methods : We analyzed 468 cases with chronic subdural hematoma admitted to the department of neurosurgery in our hospital from January 1987 to December 1996. The patients were divided into two groups according to age at presentation(group A, under 50 ; B, over 50). Results : 1) The number of group A was 126 cases(26.9%) and that of group B was 342 cases(73.1%), respectively. Males were more frequently involved than females in each group. 2) There noted a history of head trauma in 88.9% of group A and 92.4% of group B. Forty-nine patients(38.9%) of group A and 103 cases(30.1%) of group B revealed a history of alcoholism. 3) Group A patients presented with symptoms of increased intracranial pressure such as headache(75.% ), nausea and vomiting(68.0%). However, Group B patients had more frequent mental changes(84.0%) and focal neurological deficits such as hemiparesis(76.5%). 4) Onset of symptom and its duration was shorter in group A than group B. 5) Six patients among 441 cases(1.4%) treated with burr hole drainage and two patients of 27 cases(5.4%) with craniotomy died, and all of these were group B patients. The two cases among six patients with burr hole drainage developed huge intracerebral hemorrhage and brain stem hemorrhage, respectively. Conclusion : In treating patients with chronic subdural hematoma, distinguishing between two age groups is quite helpful to determine treatment strategies.

• Journal of Korean Neurosurgical Society
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• v.66 no.4
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• pp.446-455
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• 2023

Objective : Chronic subdural hematoma (CSDH) is a common neurosurgical disease and generally treated with burr-hole surgery alone. Tranexamic acid (TXA) is an antifibrinolytic agent that potentially reduces recurrence rates and the residual hematoma volume. However, the role of postoperative TXA medication remains unclear to date. This study aimed to verify the effectiveness of adjunctive TXA in the view of early hematoma resolution. Methods : Between January 2018 and September 2021, patients with CSDH who underwent burr-hole trephination in a single tertiary institute were reviewed. The study population was divided into three groups, TXA, non-TXA, and antithrombotics (AT) groups, according to the medical history of cardio-cerebrovascular disease and TXA administration. The primary endpoint was CSDH recurrence, defined as re-appearance or re-accumulation of CSDH requiring neurosurgical interventions. The secondary outcome was CSDH resolution, defined as complete or near-complete resorption of the CSDH. The CSDH resolution time and serial changes of hematoma thickness were also investigated. Results : A total of 240 patients was included in the analysis consisting of 185 male and 55 female, with a median age of 74 years. During the median imaging follow-up period of 75 days, 222 patients were reached to the primary or secondary endpoint. TXA was administered as an adjunctive therapy in 41 patients (TXA group, 16.9%) while 114 patients were included in the non-TXA group (47.9%) and 85 were in the AT group. The recurrence rate was the lowest in the TXA group (2.4%), followed by non-TXA (7.0%) and AT (8.2%) groups. However, there was no statistical significance due to the small number of patients with recurrence. CSDH resolution was achieved in 206 patients, and the median estimated time to resolution was significantly faster in the TXA group (p<0.001). Adjunctive TXA administration was a significant positive factor for achieving CSDH resolution (p<0.001). The hematoma thickness was comparable among the three groups at the initial time and after surgery. However, CSDH thickness in the TXA group decreased abruptly in a month and showed a significant difference from that in the other groups (p<0.001). There was no TXA-related adverse event. Conclusion : The adjunctive use of TXA after CSDH surgery significantly facilitated the resorption of residual CSDH and resulted in the early CSDH resolution. Adjunctive TXA may be an effective treatment option to reduce recurrence by enhancing CSDH resolution in the selective patients.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.380-389
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• 2023

Objective: Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches. Methods: In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized. Results: A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05). Conclusions: MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.

• Journal of Korean Neurosurgical Society
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• v.48 no.2
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• pp.181-184
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• 2010

A case of idiopathic hypertrophic cranial pachymeningitis (IHCP) misdiagnosed as an acute subdural hematoma is reported. A 37-year-old male patient presented with headache following head trauma 2 weeks earlier. Computerized tomography showed a diffuse high-density lesion along the left tentorium and falx cerebri. Initial chest X-rays revealed a small mass in the right upper lobe with right lower pleural thickening, which suggested lung cancer, such as an adenoma or mediastinal metastasis. During conservative treatment under the diagnosis of a subdural hematoma, left cranial nerve palsies were developed (3rd and 6th), followed by scleritis and uveitis involving both eyes. Magnetic resonance imaging (MRI) revealed an unusual tentorium-falx enhancement on gadolinium-enhanced T1-weighted images. Non-specific chronic inflammation of the pachymeninges was noticed on histopathologic examination following an open biopsy. Systemic steroid treatment was initiated, resulting in dramatic improvement of symptoms. A follow-up brain MRI showed total resolution of the lesion 2 months after steroid treatment. IHCP should be included in the differential diagnosis of subtentorial-enhancing lesions.