Elsevier

World Neurosurgery

Volume 107, November 2017, Pages 706-715
World Neurosurgery

Original Article
Clinical Investigation of Refractory Chronic Subdural Hematoma: A Comparison of Clinical Factors Between Single and Repeated Recurrences

https://doi.org/10.1016/j.wneu.2017.08.101Get rights and content

Background

Chronic subdural hematoma (CSDH) is sometimes refractory, and this is troublesome for neurosurgeons. Although many studies have reported risk factors or treatments in efforts to prevent recurrence, those have focused on single recurrence, and few cumulative data are available to analyze refractory CSDH.

Methods

We defined refractory CSDH 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.

Results

Seventy-five patients had at least 1 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 (odds ratio, 6.66, P < 0.001) and age <71 years (odds ratio, 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.

Conclusions

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 in our study.

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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    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.

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