Management and Outcome of Chronic Subdural Hematoma: A Prospective Study of Shaikh Zayed Hospital, Lahore

  • MUHAMMAD AFAQ SARWAR Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Kazim Ali Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Kamran Hussain Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Saman Shahid 2National University of Computer & Emerging Sciences (NUCES), Foundation for Advancement of Science & Technology (FAST), Lahore Pakistan.
  • Zain -ul-Aabdin Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Muhammad Abid Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Ahsun Rafi Kazmi Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Nauman Ahmad Department of Neurosurgery, Shaikh Zayed Hospital Lahore Pakistan
  • Rabia Abbas Combined Military Hospital (CMH), Lahore Pakistan
  • SAMAN SHAHID Department of Sciences & Humanities, National University of Computer & Emerging Sciences
Keywords: Chronic Subdural Hematoma, Bilateral Burr-Hole Evacuation, Trauma, Intracranial Hemorrhage

Abstract

Background/Objective: Chronic subdural hematoma (CSH) is a type of intracranial hemorrhage is commonly seen in old age. It has a poor prognosis when misdiagnosed or a delayed treatment can lead to significant morbidity. We evaluated the effectiveness of available surgical treatments for the management and outcome of CSH.
Method: The prospective cases (n = 48) of CSH were included from Department of Neurosurgery, Sheikh Zayed Hospital, Lahore during January 2014- December 2017. Detailed history of patients was taken along with comprehensive examinations with CT scans and MRIs. The CSH patients were treated surgically either with burr-hole evacuation (unilateral/bilateral) with irrigation or burr-hole drainage with drain 48 to 72 hours.
Results: The mean age of male patients was 68 years and 56 years in female patients. Most of our patients recovered (81.25%; GOS 5) uneventfully. Patients were mostly treated with burr-hole evacuation with irrigation. The 15% patients had required ICU management with GOS 2-3. Older (> 65 years) male patients were at higher risk of CSH. Trauma was not the only major cause of the CSH as history of trauma was not present in the majority (< 25%) of the patients. We found following significant risk factors, i.e., hypertension (73%), DM (62.5%) and ischemic heart disease (60%) and intake of anticoagulant/antiplatelet drugs (60%). A 4% recurrence was reported in our CSH patients. Stroke as a postoperative complication was reported in two patients (4%) and only one patient (2%) died of aspiration pneumonia.
Conclusion: Chronic subdural hematoma can be effectively treated by simple surgical intervention if diagnosed early and mortality can be reduced. We found burr-hole evacuation (unilateral/bilateral) with irrigation an effective treatment against CSH, as most of our patients (> 80%) were recovered with it. The trauma was not the only cause of CSH as history of trauma was not present in the majority of the patients, therefore, some other factors are also involved in the CSH formation in old age.

References

1. Ernestus R-I, Beldzinski P, Lanfermann H and Klug N. Chronic subdural hematoma: surgical treatment and outcome in 104 patients. World Neurosurgery, 1997; 48: 220-5.
2. Gelabert-González M, Iglesias-Pais M, García-Allut A and Martínez-Rumbo R. Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clinical neurology and neurosurgery, 2005; 107: 223-9.
3. Singla A, Jacobsen WP, Yusupov IR and Carter DA. Subdural evacuating port system (SEPS)—minimally invasive approach to the management of chronic/sub-acute subdural hematomas. Clinical neurology and neu-rosurgery, 2013; 115: 425-31.
4. Trotter W. Chronic subdural haemorrhage of traumatic origin, and its relation to pachymeningitis haemorrha-gica interna. BJS. 1914; 2: 271-91.
5. Balser D, Farooq S, Mehmood T, Reyes M and Sama-dani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Admini-stration and civilian populations. Journal of neurosur-gery, 2015; 123: 1209-15.
6. Miranda LB, Braxton E, Hobbs J and Quigley MR. Chronic subdural hematoma in the elderly: not a benign disease. Journal of neurosurgery, 2011; 114: 72-6.
7. Frontera JA, De Los Reyes K, Gordon E, et al. Trend in outcome and financial impact of subdural hemorrhage. Neurocritical care, 2011; 14: 260-6.
8. Iantosca M and Simon R. Chronic subdural hematoma in adult and elderly patients. Neurosurgery clinics of north America, 2000; 11: 447-54.
9. Mellergård P and Wisten O. Operations and re-operat-ions for chronic subdural haematomas during a 25-year period in a well defined population. Actaneurochirur-gica. 1996; 138: 708-13.
10. Ramachandran R and Hegde T. Chronic subdural hema-tomas—causes of morbidity and mortality. Surgical neurology, 2007; 67: 367-72.
11. Filippini G. Epidemiology of primary central nervous system tumors. Handbook of clinical neurology, Else-vier, 2012: p. 3-22.
12. De OJ, Pacheco H and Negron B. Chronic and subacute subdural hematoma in the adult population. The Puerto Rico experience. Puerto Rico health sciences journal, 1998; 17: 227-33.
13. Hamilton MG, Frizzell JB and Tranmer BI. Chronic subdural hematoma: the role for craniotomy reevalu-ated. Neurosurgery, 1993; 33: 67-72.
14. Ko B-S, Lee J-K, Seo B-R, Moon S-J, Kim J-H and Kim S-H. Clinical analysis of risk factors related to re-current chronic subdural hematoma. Journal of Korean Neurosurgical Society, 2008; 43: 11.
15. Asghar M, Adhiyaman V, Greenway M, Bhowmick BK and Bates A. Chronic subdural haematoma in the elde-rly—a North Wales experience. Journal of the royal society of medicine, 2002; 95: 290-2.
16. Baechli H, Nordmann A, Bucher H and Gratzl O. Dem-ographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort stu-dy. Neurosurgical review, 2004; 27: 263-6.
17. Chen J and Levy M. Causes, epidemiology, and risk factors of chronic subdural hematoma. Neurosurgery clinics of north America, 2000; 11: 399-406.
18. Sousa EB, Brandão LF, Tavares CB, Borges IB, Neto NGF and Kessler IM. Epidemiological characteristics of 778 patients who underwent surgical drainage of chronic subdural hematomas in Brasília, Brazil. BMC surgery, 2013; 13: 5.
19. Suzuki J and Komatsu S. Estrogen in patients with chronic subdural hematoma. Surgical neurology, 1977; 8: 243-7.
20. Kudo H, Kuwamura K, Izawa I, Sawa H and Tamaki N. Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect. Neurologia medico-chirurgica. 1992; 32: 207-9.
21. Maurice-Williams R and Kitchen N. The scope of neu-rosurgery for elderly people. Age and ageing, 1993; 22: 337-42.
22. Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H and Endo S. Independent predictors of recur-rence of chronic subdural hematoma: results of multi-variate analysis performed using a logistic regression model. Journal of neurosurgery, 2003; 98: 1217-21.
23. Adhiyaman V, Asghar M, Ganeshram K and Bhow-mick B. Chronic subdural haematoma in the elderly. Postgraduate medical journal, 2002; 78: 71-5.
24. Havenbergh TV, Calenbergh FV, Goffin J and Plets C. Outcome of chronic subdural haematoma: analysis of prognostic factors. British journal of neurosurgery, 1996; 10: 35-9.
25. Abouzari M, Rashidi A, Rezaii J, et al. The role of post-operative patient posture in the recurrence of traumatic chronic subdural hematoma after burr-hole surgery. Neurosurgery, 2007; 61: 794-7.
26. Ohba S, Kinoshita Y, Nakagawa T and Murakami H. The risk factors for recurrence of chronic subdural hematoma. Neurosurgical review, 2013; 36: 145-50.
27. MORI K and MAEDA M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complicat-ions, and recurrence rate. Neurologia medico-chirur-gica. 2001; 41: 371-81.
28. Santarius T, Kirkpatrick PJ, Ganesan D, et al. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. The Lancet. 2009; 374: 1067-73.
29. Markwalder T-M. Chronic subdural hematomas: a re-view. Journal of neurosurgery, 1981; 54: 637-45.
30. Sarnvivad P, Chiewchanvechakul W and Chumnanvej S. Chronic subdural hematoma: drainage vs. no drai-nage. Journal of the Medical Association of Thailand, 2011; 94: 1352.
31. Yang AI, Balser DS, Mikheev A, et al. Cerebral atro-phy is associated with development of chronic subdural haematoma. Brain injury, 2012; 26: 1731-6.
32. Lee K. The pathogenesis and clinical significance of traumatic subdural hygroma. Brain injury, 1998; 12: 595-603.
33. Apfelbaum RI, Guthkelch A and Shulman K. Experi-mental production of subdural hematomas. Journal of neurosurgery, 1974; 40: 336-46.
34. Hart RG, Boop BS and Anderson DC. Oral anticoagu-lants and intracranial hemorrhage: facts and hypotheses. Stroke, 1995; 26: 1471-7.
35. Fujisawa H, Ito H, Saito K, Ikeda K, Nitta H and Yam-
ashita J. Immunohistochemical localization of tissue-type plasminogen activator in the lining wall of chronic subdural hematoma. Surgical neurology, 1991; 35: 441-5.
36. Tanaka Y and Ohno K. Chronic subdural hematoma–an up-to-date concept. Journal of medical and dental sciences, 2013; 60: 55-61.
37. Ito U, Fujimoto T and Inaba Y. Formation of the chro-nic subdural hematoma: 1. Clinico-pathological study of the chronic subdural hematoma (author's transl). No shinkeigeka Neurological surgery, 1974; 2: 47-61.
38. Nakamura N. Relationship between head injuries and chronic subdural hematoma. No to shinkei= Brain and nerve, 1966; 18: 702-9.
39. Sato M, Nakano M, Sasanuma J, Asari J and Watanabe K. Very late onset of chronic subdural hematoma. Neu-rologia medico-chirurgica. 2005; 45: 41-3.
40. Yamashima T and Friede R. Why do bridging veins rupture into the virtual subdural space? Journal of Neu-rology, Neurosurgery & Psychiatry, 1984; 47: 121-7.
41. Lee J-Y, Ebel H, Ernestus R-I and Klug N. Various sur-gical treatments of chronic subdural hematoma and out-come in 172 patients: is membranectomy necessary? Surgical neurology, 2004; 61: 523-7.
42. Ivamoto HS, Lemos HP and Atallah AN. Surgical treat-ments for chronic subdural hematomas: a comprehen-sive systematic review. World neurosurgery, 2016; 86: 399-418.
43. Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M and Yamagata S. Independent predictors for recur-rence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery, 2008; 63: 1125-9.
44. Oishi M, Toyama M, Tamatani S, Kitazawa T and Saito M. Clinical factors of recurrent chronic subdural hema-toma. Neurologia medico-chirurgica, 2001; 41: 382-6.
45. Weigel R, Schmiedek P and Krauss J. Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. Journal of Neurology, Neuro-surgery & Psychiatry, 2003; 74: 937-43.
Published
2018-03-31
Section
Original Articles