• Journal of Korean Neurosurgical Society
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• v.61 no.1
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• pp.97-104
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• 2018

Objective : Diffusion-weighted magnetic resonance imaging (DW-MRI) has proven useful in the study of the natural history of ischemic stroke. However, the potential of DW-MRI for the evaluation of chronic subdural hematoma (CSDH) has not been established. In this study, we investigated DW-MRI findings of CSDH and evaluated the impact of the image findings on postoperative outcomes of CSDH. Methods : We studied 131 CSDH patients who had undergone single burr hole drainage surgery. The images of the subdural hematomas on preoperative DW-MRI and computed tomography (CT) were divided into three groups based on their signal intensity and density : 1) homogeneous (iso or low) density on CT and homogeneous low signal intensity on DW-MRI; 2) homogeneous (iso or low) density on CT and mixed signal intensity on DW-MRI; and 3) heterogeneous density on CT and mixed signal intensity on DW-MRI. On the basis of postoperative CT, we also divided the patients into 3 groups of surgical outcomes according to residual hematoma and mass effect. Results : Analysis showed statistically significant differences in surgical (A to B : p<0.001, A to C : p<0.001, B to C : p=0.129) and functional (A to B : p=0.039, A to C : p<0.001, B to C : p=0.108) outcomes and treatment failure rates (A to B : p=0.037, A to C : p=0.03, B to C : p=1) between the study groups. In particular, group B and group C showed worse outcomes and higher treatment failure rates than group A. Conclusion : CSDH with homogeneous density on CT was characterized by signal intensity on DW-MRI. In CSDH patients, performing DW-MRI as well as CT helps to predict postoperative treatment failure or complications.

• Journal of Korean Neurosurgical Society
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• v.50 no.2
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• pp.103-108
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• 2011

Objective : There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results. Methods : Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization. Results : The mean ages were $69.4{\pm}12.1$ and $55.6{\pm}9.3$ years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups. Conclusion : Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique.

• Journal of Korean Neurosurgical Society
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• v.46 no.3
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• pp.210-214
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• 2009

Objective : Several surgical procedures have been reported for the treatment of chronic subdural hematoma (CSDH). We compared the results of treatments for CSDH obtained from one burr-hole craniostomy with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation, and small craniotomy with irrigation and closed-system drainage. Methods : Eighty-seven patients with CSDH underwent surgery at our institution from January 2004 to December 2008. Our patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n=25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n=32), and group III, small craniotomy with irrigation and closed-system drainage (n=30). Results : Age distribution, male and female ratio, Markwalder's grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer. Conclusion : Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH.

• Journal of Korean Neurosurgical Society
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• v.65 no.1
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• pp.123-129
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• 2022

Objective : Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years. Methods : This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1-6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated. Results : Their mean age was 92.8 years and the median was 92.4 years (range, 90-100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups. Conclusion : In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

• Journal of Korean Neurosurgical Society
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• v.43 no.1
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• pp.11-15
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• 2008

Objective : Burr hole drainage has been widely used to treat chronic subdural hematoma (CSDH). However, the incidence of recurrent CSDH varies from 3.7 to 30% after surgery. The authors attempted to elucidate the risk factors associated with the recurrence of CSDH in one burr hole drainage technique. Methods : A total of 255 consecutive cases who underwent one burr hole drainage for CSDH were included in this study. Twenty-four patients (9.4%) underwent a repeated operation because of the recurrence of CSDH. We analyzed retrospectively the demographic, clinical and radiologic factors associated with the recurrence of CSDH. Results : In this study, two risk factors were found to be independently associated with the recurrence of CSDH. The incidence of CSDH recurrence in the high- and mixed-density groups was significantly higher than those in the low- and iso-density groups (p<0.001). Bleeding tendency such as in leukemia, liver disease and chronic renal failure was also significantly associated with recurrence of CSDH (p=0.037). Conclusion : These results suggest that high- and mixed- density shown on computed tomographic scan was closely relates with a high incidence of recurrence. Therefore, the operation could be delayed in those cases unless severe symptoms or signs are present. Reoperation using the previous burr hole site is a preferred modality to treat the recurrent CSDH.

• 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.