Original ArticleClinical Investigation of Refractory Chronic Subdural Hematoma: A Comparison of Clinical Factors Between Single and Repeated Recurrences
Introduction
Chronic subdural hematoma (CSDH) is one of the most common diseases seen by neurosurgeons and is usually associated with good recovery after treatment with burr-hole irrigation and drainage under local anesthesia.1, 2, 3, 4, 5, 6, 7 Despite this situation, approximately 5%–33% of patients experience recurrence and require reoperation.1, 2, 3, 4, 5 Although recurrence usually involves only a single episode, repeated recurrences (i.e., refractory CSDH) sometimes occur. Refractory CSDH is often challenging for both neurosurgeons and patients, because of the need for repeat surgeries and the associated risks, complications, and costs. To prevent refractory CSDH, knowing the risk factors and performing effective treatments is important for patients with these risk factors when the first recurrence occurs.
Many studies have reported risk factors associated with recurrence of CSDH or treatments for reduction of recurrence. Risk factors for recurrence are split into 3 groups: patient-related, radiologic, and surgical.8 Patient-related risk factors include older age, male sex, brain atrophy, hepatic dysfunction, cardiac disease, malignant neoplasm, diabetes mellitus, use of anticoagulant or antiplatelet drugs, hemodialysis, blood coagulopathy disorder, chronic alcoholism, or conditions associated with cerebrospinal fluid (CSF) shunt placement.3, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Radiologic risk factors include bilateral hematomas, mixed-density or high-density hematoma on computed tomography (CT), or larger hematoma volume.8, 11, 16, 17, 18, 19, 20, 21 Surgical risk factors include lack of closed-system drainage.8 In addition, specific hematoma subtype such as septated or organized CSDH is often associated with recurrence.16, 22, 23 On the other hand, artificial CSF as an intraoperative irrigation solution or adjunctive therapies such as steroid, angiotensin-converting enzyme inhibitor, tranexamic acid, atorvastatin, and Kampo medicine have often been used for preventing recurrence.24, 25, 26, 27, 28, 29, 30, 31
Although many risk factors and treatments have been reported, as described earlier, these factors have been inconsistent and contraversial.17 Moreover, the focus has been on single recurrence, and few cumulative data have been collected to analyze refractory CSDH. We therefore hypothesized that refractory CSDH might be a different type of CSDH or that patients with refractory CSDH might show different or significantly more risk factors than do patients with single recurrence of CSDH.
The present cohort study analyzed patients with recurrence of CSDH and examined whether patients with refractory CSDH show different or significantly more risk factors than patients with single recurrence, and whether effective treatments for reduction of refractory CSDH exist.
Section snippets
Methods
This study was approved by the institutional review board of our hospital. The prospectively maintained database of our hospital was searched for patients with CSDH between January 2010 and December 2015. Medical records, radiographic studies, operative reports, and clinical follow-up evaluations were reviewed retrospectively. Patient informed consent was obtained before surgery.
Results
Among 75 patients with recurrence of CSDH, 62 had a single recurrence and 13 developed ≥2 recurrences by 3 months after the last operation. The rate of refractory CSDH was thus 2.3%.
Discussion
The rate of refractory CSDH has been reported to be approximately 5%.23, 35 Our rate of refractory CSDH was 2.3%. Refractory CSDH sometimes occurs and is troublesome for neurosurgeons.
Conclusions
Our results show that a first recurrence within 1 month, age younger than 71 years, and organized hematoma are risk factors for refractory CSDH. These factors indicate that refractory CSDH may be a more active type of CSDH with aggressive local inflammation and angiogenesis. Moreover, our results show a possibility that burr-hole irrigation with closed-system drainage does not always prevent refractory CSDH. Hence, when patients with the risk factors for refractory CSDH have a recurrence,
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Cited by (16)
The Danish Chronic Subdural Hematoma Study—Risk Factors for Second Recurrence
2022, World NeurosurgeryCitation Excerpt :In the re-CSDH population, midline shift turned out to be an independent risk factor for re-re-CSDH. Albeit midline shift was only identified as a risk factor for re-re-CSDH in patients with re-CSDH, a similar result has been found in previous studies.10-12 Generally, large midline shift on preoperative CT-C should be considered alarming regarding the risk of recurrence.
Embolization of the Middle meningeal artery in chronic subdural hematoma — A systematic review
2019, Clinical Neurology and NeurosurgeryCitation Excerpt :Strategies tested to non-invasively address this growth have included dexamethasone [3] as well as tranexamic acid [9]. Recently, several case reports and two prospective studies suggested that embolization of the MMA could inhibit the influx of blood into this membrane and thus prevent the accumulation of the hematoma in the subdural space [10–12]. The goal of this study was to systematically review all published cases of MMA embolization (MMAE) in cSDH to assess the procedure’s safety, feasibility, indications and efficacy.
Enhanced Hematoma Membrane on DynaCT Images During Middle Meningeal Artery Embolization for Persistently Recurrent Chronic Subdural Hematoma
2019, World NeurosurgeryCitation Excerpt :Although the merits of various surgical methods, including removal of the outer membrane capsule via a large craniotomy, creating a subdural–peritoneal shunt, placing an Ommaya reservoir, and endoscopic surgery, have been argued, a curative strategy has not been established.20,21 Embolization of the MMA is considered to inhibit the blood supply to the neovasculature of the hematoma membrane and to prevent CSDH recurrence,8,22 which is reasonable and effective because the treatment focus is the origin of bleeding. Several reports have described MMA embolization to treat recurrent CSDH with generally good treatment outcomes and without complications.9-11
Recurrence in 787 Patients with Chronic Subdural Hematoma: Retrospective Cohort Investigation of Associated Factors Including Direct Oral Anticoagulant Use
2018, World NeurosurgeryCitation Excerpt :In the current study, we found that antithrombotic agents such as aspirin and warfarin did not increase CSDH recurrence. This finding was in line with results of previous studies,1,9,10,19 although some studies have reported that antithrombotic agents are risk factors for recurrence.4,8,20 Considering the pathogenesis of CSDH, it is hypothesized that microhemorrhage into the hematoma cavity is related to recurrence.
Which surgical procedure is effective for refractory chronic subdural hematoma? Analysis of our surgical procedures and literature review
2018, Journal of Clinical NeuroscienceCitation Excerpt :Because the focus of treatment is on addressing the origin of bleeding, this method appears reasonable and effective. Several reports have described embolization of the MMA for refractory CSDH [9,18–28], and Table 2 summarizes the clinical features and results. Although treatment outcomes have generally been good, some cases developed recurrence [18,28].
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.