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Key Clinical Message: Middle meningeal artery embolization is a valuable alternative for chronic subdural hematoma refractory to Burr hole surgery. In a 61‐year‐old patient, this endovascular intervention effectively resolved the hematoma alleviating associated symptoms. [ABSTRACT FROM AUTHOR]

Key Clinical Message Middle meningeal artery embolization is a valuable alternative for chronic subdural hematoma refractory to Burr hole surgery. In a 61‐year‐old patient, this endovascular intervention effectively resolved the hematoma alleviating associated symptoms.

IntroductionChronic subdural hematoma (CSDH) is commonly treated using simple burr hole surgery. However, postoperative recurrence occurs at a relatively high rate of 10–20%. A decrease in platelet count (PC) may be associated with recurrence via a hemostasis disorder; however, this association has not been well-studied. Therefore, this study aimed to investigate the association between PC and postoperative CSDH recurrence.MethodsWe retrospectively reviewed the data for CSDHs in 488 cerebral hemispheres of 431 patients who underwent burr hole surgery at our institution between January 2013 and December 2022. The association between preoperative PC and postoperative CSDH recurrence was investigated. We used the first quartile of PC, PC

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.

Objective: Subdural hematomas (SDH) are classified clinically and/or radiologically as acute (ASDH), subacute (SSDH) and chronic (CSDH). The management differ depending on their classification, with only the ASDH having a definite accepted surgical guideline. Non-acute SDH, specifically SSDH and CSDH have no clear surgical guidelines but are managed similarly in some literature. This study was conducted to determine if there is a difference in outcomes among surgically managed non-acute SDH in a specific elderly population of retired military personnel., Methods: This is a pre-pandemic retrospective study that utilized data obtained from January 2016 to April 2019, in a subspecialty tertiary hospital that caters to retired military personnel or veterans, in the Philippines. After chart review and application of inclusion and exclusion criteria, twenty-one patients were included, all military retirees, with age 56 years old and above. Chart review and electronic database were retrieved to extract relevant information., Results: In this study, a term 'mixed-type subdural hematoma' (MSDH) was proposed to encompass SDH that have mixed hypo-and-hyperdensity on preoperative CT scan and were subsequently found to have bright red liquefied hematoma instead of the classic engine machinery oil fluid found in a CSDH. Based on the observed cohort, 9 out of 11 CSDH patients attained the Glasgow Outcome Scale Extended (GOS-E) score of 8 while all the respondents in the MSDH group attained the same GOS-E score underscoring the need for early intervention in patients with non-acute subdural hematoma. Moreover, the outcomes of both MSDH and CSDH are comparable with low mortality rate (~9.5%) and immediate postoperative improvement (~90%)., Conclusion: MSDH and CSDH, although classified separately using clinical and/or radiologic means, can collectively be categorized as a non-acute SDH and can be managed safely and effectively with burr hole surgery.

Purpose: Multiple burr hole surgery is considered to be an option for achieving indirect revascularization in patients with ischemic Moyamoya disease (MMD). We aimed to investigate the efficacy of stand-alone multiple burr hole surgery for salvage revascularization in patients with MMD by assessing the hemodynamic changes via normalized time-to-peak (nTTP) analysis and independent component analysis (ICA) of preoperative and postoperative dynamic susceptibility contrast (DSC) perfusion MRI data. Methods: The DSC perfusion MRI data of 25 hemispheres from 21 patients with MMD, who underwent multiple burr hole surgery for salvage revascularization due to persistent or recurrent symptoms after primary revascularization with modified encephaloduroarteriosynangiosis (mEDAS), were analyzed. The nTTP, which was measured using the region of interests covering the entire surgical hemisphere, was compared between the preoperative and postoperative images. ICA was used to compare the relative arterial and venous components of the surgical hemispheres between the respective preoperative and postoperative images. Results: The median postoperative nTTP (1.80 s) was significantly shorter than the median preoperative nTTP (4.10 s) (P < 0.001). The postoperative relative arterial component of the surgical hemisphere (median: 0.04) was significantly higher than the preoperative relative arterial component (median: − 0.02, P < 0.001). In contrast, the postoperative relative venous component of the surgical hemisphere (median: − 0.05) was significantly lower than the preoperative value (median: 0.05, P < 0.001). Conclusion: The improvement in cerebral perfusion parameters observed on postoperative DSC perfusion MRI demonstrated that stand-alone multiple burr hole surgery could be a favorable salvage revascularization technique after mEDAS failure in patients with ischemic MMD. [ABSTRACT FROM AUTHOR]

PurposeThe purpose of the current study was to compare the effects of local anesthesia (LA) and general anesthesia (GA) on the surgical process and postoperative recovery of patients with unilateral chronic subdural hematoma (CSDH).Patients and MethodsA retrospective cohort study was conducted on patients with unilateral CSDH who underwent burr hole surgery between the years 2013 and 2018. Patients who received local anesthesia were allocated to the LA group, and the patients who received general anesthesia were allocated to the GA group. The clinical data, postoperative complication, length of stay, and hospitalization cost of these two groups were compared and analyzed.ResultsData from 105 patients was collected for this study. Fifty one patients were assigned to the LA group and 54 to GA group. The duration of anesthesia and operation of the LA group was 37.71 (10.55) min; while for the GA group the duration was 56.04 (8.37) min (p < 0.001). The time from operation to discharge in GA group was greatly longer than that in LA group [(8.51 (1.49) days vs. 10.46 (2.34) days, respectively; p < 0.001]. Hospitalization cost for LA group was 2,721.54 (504.66) USD, which was significantly lesser than that for GA patients [3,314.82 (493.52) USD; p < 0.001]. The total number of complications in LA patients was less than that in GA patients [6 vs. 29 cases, respectively; p < 0.001]. The number of patients with residual hematoma in the LA group was

Background: Brainstem anesthesia is a transient loss of brainstem function usually associated with retrobulbar block and rarely seen by neurosurgeons. Case Description: Here, we report a case of brainstem anesthesia during shunt revision operation in a 79-yearold woman. Local anesthesia administered at the end of surgery was thought to have infiltrated the subarachnoid space through a burr hole, causing prolonged unconsciousness and cranial nerves’ impairment. Spontaneous resolution occurred during systemic support. Conclusion: As brainstem anesthesia may occur by leakage of local anesthetic through small burr holes, timing injections carefully can avoid this rare complication. [ABSTRACT FROM AUTHOR]

The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Acute subdural hematoma (ASDH) is a common disease and craniotomy is the first choice for removing hematoma. However, patients for whom craniotomy or general anesthesia is contraindicated are increasing due to population aging. In our department, we perform burr hole surgery under local anesthesia with urokinase administration for such patients. We compared the patient background and outcomes between burr hole surgery and craniotomy to investigate the surgical safety criteria for burr hole surgery. Methods: We reviewed 24 patients who underwent burr hole surgery and 33 patients who underwent craniotomy between January 2010 and April 2020 retrospectively. Results: The median age of the burr hole surgery group was older (P = 0.01) and they had multiple pre-existing conditions. Compared with the craniotomy group, neurological deficits and CT findings were minor in the burr hole surgery group, whereas the maximum hematoma thickness was not significantly different. The hematoma was excreted after a total of 54,000 IU of urokinase was administered for a median of 3 days. The Glasgow Coma Scale score improved in all patients in the burr hole surgery group and there were no deaths. Age, especially over 65 y.o., (OR 1.16, 95% CI 1.04-1.30) and the absence of basal cistern disappearance (OR 0.04, 95% CI 0.004-0.39) were significant factors. Conclusion: Burr hole surgery was performed safely in all patients based on the age, especially older than 65 y.o., and the absence of basal cistern disappearance. ASDH in the elderly is increasing and less invasive burr hole surgery with urokinase is suitable for the super-aging society. [ABSTRACT FROM AUTHOR]

Background: Chronic subdural hematomas (CSDHs) mainly occur in elderly people and usually develop after minor head injuries. CSDH can be cured by a relatively simple burr hole surgery. Rarely reported, hemorrhagic postsurgical complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood. Case Description: We report the case study of an 89-year-old man with CSDH who presented with the right hemiparesis. He underwent burr hole surgery with a closed-drainage system. A computed tomography (CT) scan conducted the following day demonstrated an acute intraventricular hemorrhage and hyperperfusion of the ipsilateral hemisphere. Conclusion: This is a rare case of an acute hematoma in the ventricle following drainage of a CSDH. The likely mechanism of this intraventricular hemorrhage could be that the drainage of the hematoma produced a movement of the ventricle and hemisphere accompanied by hyperperfusion. [ABSTRACT FROM AUTHOR]

When performing burr hole endoscopic neurosurgery, it is necessary to get enough surgical corridor. We have used various instruments to extend burr hole size, but it was cumbersome to use so many tools. In this report, we describe a novel instrument—a dilator attachment with a cordless handle to make it simple and safe to extend a burr hole. We developed this burr hole dilator attachment with blades on the side and an arc form on the bottom to prevent dural damage. It can be used to drill safely and efficiently. We describe some experiences of using this device. It is important to balance the maximization of the operation range and surgical invasiveness for endoscopic neurosurgery. This new dilator for extending a burr hole is a safe, useful device to get enough surgical view and easily perform a surgical procedure in endoscopic surgery. Our dilator for expanding a burr hole improves the work of endoscopic surgery on intracranial hemorrhagic lesions. [ABSTRACT FROM AUTHOR]

Background Although chronic subdural hematoma (CSDH) has a good prognosis after classical minimally-invasive drainage surgery, severe complications still occur at a substantial rate. Cerebral hyperperfusion syndrome (CHS), which is a common severe complication after carotid endarterectomy or carotid artery stenting for cervical carotid artery stenosis, is rare after drainage surgery for a CSDH. Case Description We describe the case of an 82-year-old woman who presented with ipsilesional symptoms including contralateral hemiparesis and dysarthria, progressively worsening consciousness, and status epilepticus after a burr hole drainage surgery for CSDH. Magnetic resonance fluid-attenuated inversion recovery imaging showed diffuse subcortical low intensity in the ipsilesional hemisphere almost simultaneously with the appearance of the symptoms. Arterial spin labeling magnetic resonance perfusion imaging showed the abnormal increase of cerebral blood flow in the hemisphere. Continuous propofol administration and blood pressure management improved the symptoms. Conclusions CHS can cause severe postoperative complications after drainage surgery for CSDH. Subcortical low-intensity fluid-attenuated inversion recovery imaging is a useful investigation for early detection of CHS in CSDH, and arterial spin labeling imaging is an effective minimally-invasive modality for confirming the diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Chronic subdural hematoma (CSDH) is commonly treated using simple burr hole surgery. However, postoperative recurrence occurs at a relatively high rate of 10-20%. A decrease in platelet count (PC) may be associated with recurrence via a hemostasis disorder; however, this association has not been well-studied. Therefore, this study aimed to investigate the association between PC and postoperative CSDH recurrence., Methods: We retrospectively reviewed the data for CSDHs in 488 cerebral hemispheres of 431 patients who underwent burr hole surgery at our institution between January 2013 and December 2022. The association between preoperative PC and postoperative CSDH recurrence was investigated. We used the first quartile of PC, PC < 170 × 10 3 /μL to define a threshold for decreased PC., Results: In total, 459 cerebral hemispheres with CSDHs in 405 patients were followed up postoperatively for at least 3 months or until CSDH disappeared. CSDH recurred in 39 (8.5%) cerebral hemispheres. The recurrence rate was gradually increased in parallel with a decreasing PC. Among 109 CSDHs with a decreased PC (<170 × 10 3 /μL), 15 (13.8%) recurred, whereas only 24 (6.9%) of 350 CSDHs without a decreased PC recurred ( p  = 0.03). In univariable logistic analysis, eosinophil-rich blood (≥100/μL eosinophils in peripheral blood) and a decreased PC were significant risk factors. Multivariable analysis showed that eosinophil-rich blood (adjusted odds ratio, 2.51; 95% confidence interval, 1.26-4.99; p  = 0.009) and a decreased PC (adjusted odds ratio, 2.15; 95% confidence interval, 1.07-4.35; p  = 0.03) were independent risk factors for recurrence., Conclusion: Our study showed that a decrease in PC was associated with postoperative CSDH recurrence. Patients with CSDH and a decreased PC require careful postoperative follow-up., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yagi, Matsubara, Kanda, Minami and Hishikawa.)

Objective We established a reliable nomogram model to predict the recurrence of chronic subdural hematoma (CSDH) after burr hole surgery. Methods We retrospectively analyzed 514 patients who were treated in our hospital between January 2010 and November 2017 and included 231 patients in this study. We used univariate and binary logistic regression analysis to identify the significantly related predictors for recurrence. Subsequently, we established the nomogram model using these predictors and validated it. Results The total rate of recurrence after initial surgery for CSDH was 14.29% (33/231) during the following 3 months. We found that preoperative hematoma volume (greater than 121 mL), postoperative residual cavity volume (greater than 72 mL), computed tomography scan imaging type (hyper- and mixed-density type), and age (older than 65 years of age) were significantly related to recurrence. We used 50% recurrence rate as the classification cutoff, with the corresponding points of 252 to validate the nomogram model. The accuracy of predicting the recurrence of CSDH calculated by the binary logistic regression model was 91.7%. The sensitivity and specificity of the nomogram were 87.88% and 84.85%, respectively. Conclusions This nomogram model had a high precision to predict the recurrence of CSDH. It needs more external and prospective validation in the future. We expect this model could be used in different neurosurgical problems as well. [ABSTRACT FROM AUTHOR]

Background Chronic subdural hematoma (CSDH) is a common intracranial hematoma. The number of patients who undergo anticoagulant therapy including a direct oral anticoagulant (DOAC) is expected to increase. Recently, idarucizumab, the antidote for dabigatran, which is a DOAC, has been developed. We successfully treated CSDH with dabigatran using emergency burr hole surgery and idarucizumab. Case Description A 79-year-old Japanese man severely hit his head and visited the emergency department. Computed tomography (CT) showed tiny traumatic acute subdural hematoma, for which he was admitted. At that time, atrial fibrillation was newly detected, for which dabigatran, having a specific antidote (idarucizumab), was chosen and started 2 weeks after the discharge. Two months after the trauma episode, he revisited the emergency department because of acute left upper and lower limb motor weakness. CT revealed a midline shifted CSDH. Considering rush course of motor weakness and shifted brain, we performed emergency surgery using an antidote for dabigatran, idarucizumab. He was discharged 5 days after surgery without any complications or excessive perioperative hemorrhage. Conclusion Dabigatran should be used for atrial fibrillation detected after head trauma. Emergency surgery can be safely performed for CSDH with dabigatran using idarucizumab. [ABSTRACT FROM AUTHOR]

Objective: Approximately 10 % of patients with chronic subdural hematoma (CSDH) undergo reoperation after initial surgery. This study aimed to develop a predictive model for the recurrence of unilateral CSDH at initial surgery without hematoma volumetric analysis., Methods: This single-center retrospective cohort study evaluated pre- and postoperative computed tomography (CT) images of patients with unilateral CSDH. The pre- and postoperative midline shift (MLS), residual hematoma thickness, and subdural cavity thickness (SCT) were measured. CT images were classified based on the internal architecture of the hematoma (homogenous, laminar, trabecular, separated, and gradation subtypes)., Results: Total 231 patients with unilateral CSDH underwent burr hole craniostomy. After receiver operating characteristic analysis, preoperative MLS and postoperative SCT showed better areas under the curve (AUCs) (0.684 and 0.756, respectively). According to the CT classification of preoperative hematomas, the recurrence rate was significantly higher in the separated/gradation group (18/97, 18.6 %) than in the homogenous/laminar/trabecular group (10/134, 7.5 %). Four-point score was derived from the multivariate model using the preoperative MLS, postoperative SCT, and CT classification. The AUC of this model was 0.796, and the recurrence rates at 0-4 points were 1.7 %, 3.2 %, 13.3 %, 25.0 %, and 35.7 %, respectively., Conclusion: Pre- and postoperative CT findings without hematoma volumetric analysis may predict CSDH recurrence., Competing Interests: Conflicts of interest M.M.’s son-in-law worked at IQVIA Services Japan K.K, contract research and a contract sales organization. M.M.’s son-in-law works at Syneos Health Clinical K.K, contract research and a contract sales organization. The other authors declare no competing interests., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.

Objective: Chronic subdural hematoma (CSDH) is a common neurological disease with a significant postoperative recurrence rate. There are numerous reported studies of the development of CSDH. In recent years, fibrinolysis, angiogenesis, and inflammation have all been identified as relevant factors in the development of CSDH. While several authors have reported risk factors associated with CSDH recurrence, differential blood count of leukocytes has not yet been discussed. Therefore, in this study the authors aimed to retrospectively investigate the association between differential blood leukocyte count and the rate of CSDH recurrence., Methods: The authors retrospectively reviewed 476 patients with 529 CSDHs who underwent surgery at a single institution between January 2011 and December 2021. After exclusion of patients who had not undergone a differential blood test of leukocytes preoperatively, CSDHs in 517 cerebral hemispheres of 466 patients were included in the study. Peripheral blood eosinophil counts ≥ 100/µL were considered eosinophil rich., Results: CSDHs in 494 cerebral hemispheres of 445 patients were followed up postoperatively for at least 3 months or until resolution indicated by CSDH disappearance. Postoperative recurrence of CSDH was observed in 46 cerebral hemispheres (9.3%). Among the preoperative differential blood counts of all leukocytes, eosinophils alone were significantly associated with CSDH recurrence (median [IQR] 76/µL [30-155/µL] vs 119/µL [39-217/µL]; p = 0.03). Multivariable regression analysis showed thrombocytopenia (adjusted OR [aOR] 5.23, 95% CI 1.85-14.79; p = 0.002), use of anticoagulant drugs (aOR 2.51, 95% CI 1.17-5.38; p = 0.02), hematoma volume (10 mL per increase) (aOR 1.08, 95% CI 1.00-1.16; p = 0.04), and eosinophil-rich peripheral blood (aOR 2.22, 95% CI 1.17-4.23; p = 0.02) were all independent predictors for CSDH recurrence., Conclusions: This study showed that preoperative peripheral blood eosinophil count was an independent risk factor for CSDH recurrence. Therefore, patients with CSDH who have elevated eosinophils preoperatively in peripheral blood require careful follow-up.

Purpose: The purpose of the current study was to compare the effects of local anesthesia (LA) and general anesthesia (GA) on the surgical process and postoperative recovery of patients with unilateral chronic subdural hematoma (CSDH)., Patients and Methods: A retrospective cohort study was conducted on patients with unilateral CSDH who underwent burr hole surgery between the years 2013 and 2018. Patients who received local anesthesia were allocated to the LA group, and the patients who received general anesthesia were allocated to the GA group. The clinical data, postoperative complication, length of stay, and hospitalization cost of these two groups were compared and analyzed., Results: Data from 105 patients was collected for this study. Fifty one patients were assigned to the LA group and 54 to GA group. The duration of anesthesia and operation of the LA group was 37.71 (10.55) min; while for the GA group the duration was 56.04 (8.37) min ( p < 0.001). The time from operation to discharge in GA group was greatly longer than that in LA group [(8.51 (1.49) days vs. 10.46 (2.34) days, respectively; p < 0.001]. Hospitalization cost for LA group was 2,721.54 (504.66) USD, which was significantly lesser than that for GA patients [3,314.82 (493.52) USD; p < 0.001]. The total number of complications in LA patients was less than that in GA patients [6 vs. 29 cases, respectively; p < 0.001]. The number of patients with residual hematoma in the LA group was

Background: Acute subdural hematoma (ASDH) is a common disease and craniotomy is the first choice for removing hematoma. However, patients for whom craniotomy or general anesthesia is contraindicated are increasing due to population aging. In our department, we perform burr hole surgery under local anesthesia with urokinase administration for such patients. We compared the patient background and outcomes between burr hole surgery and craniotomy to investigate the surgical safety criteria for burr hole surgery., Methods: We reviewed 24 patients who underwent burr hole surgery and 33 patients who underwent craniotomy between January 2010 and April 2020 retrospectively., Results: The median age of the burr hole surgery group was older ( P = 0.01) and they had multiple pre-existing conditions. Compared with the craniotomy group, neurological deficits and CT findings were minor in the burr hole surgery group, whereas the maximum hematoma thickness was not significantly different. The hematoma was excreted after a total of 54,000 IU of urokinase was administered for a median of 3 days. The Glasgow Coma Scale score improved in all patients in the burr hole surgery group and there were no deaths. Age, especially over 65 y.o., (OR 1.16, 95% CI 1.04-1.30) and the absence of basal cistern disappearance (OR 0.04, 95% CI 0.004-0.39) were significant factors., Conclusion: Burr hole surgery was performed safely in all patients based on the age, especially older than 65 y.o., and the absence of basal cistern disappearance. ASDH in the elderly is increasing and less invasive burr hole surgery with urokinase is suitable for the super-aging society., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Surgical Neurology International.)

In Asian countries, herbal medicines have been used to treat Chronic subdural hematoma (CSDH) as an adjunctive therapy. This review aims to evaluate the efficacy and safety of herbal medicine on treating CSDH and preventing recurrent CSDH. A literature search was conducted on PubMed, CENTRAL, Scopus, CiNii, KTKP, NDSL, OASIS, and CNKI for randomized controlled trials that evaluated the effects of herbal medicines on CSDH. Seven studies (n = 646) were included. The overall methodological quality of these studies was low. In the herbal group, the meta-analysis indicated statistically significant improvements in the total effective rate and recurrence rate as compared with those in the non-herbal group. Herbal treatments were found to be relatively safe. Herbal medicines might be efficacious in the management of CSDH and prevent its recurrence. Further rigorous studies will have to be conducted in order to make more definite conclusions. • This review evaluated efficacy and safety of herbal medicine on treating chronic subdural hematoma. • Seven studies were included in meta-analysis. The methodological quality was low. • Herbal group revealed significant improvements compared with non-herbal group. • Herbal medicine might be efficacious in the management without side effects. • Further rigorous studies will have to be conducted. [ABSTRACT FROM AUTHOR]

Burr hole surgery in the emergency room can be lifesaving for patients with acute subdural hematoma (ASDH). In the first part of this study, a strategy of combined burr hole surgery, a period of intracranial pressure (ICP) monitoring, and then craniotomy was examined for safe and effective treatment of ASDH. Since 2012, 16 patients with severe ASDH with indications for burr hole surgery were admitted to Kenwakai Otemachi Hospital. From 2012 to 2016, craniotomy was performed immediately after burr hole surgery (emergency [EM] group, n = 10). From 2017, an ICP sensor was placed before burr hole surgery. After a period for correction of traumatic coagulopathy, craniotomy was performed when ICP increased (elective [EL] group, n = 6). Patient background, bleeding tendency, intraoperative blood transfusion, and outcomes were compared between the groups. In the second part of the study, ICP was measured before and after burr hole surgery in seven patients (including two of the six in the EL group) to assess the effect of this surgery. Activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were significantly prolonged after craniotomy in the EM group, but not in the EL group, and the EM group tended to require a higher intraoperative transfusion volume. The rate of good outcomes was significantly higher in the EL group, and ICP was significantly decreased after burr hole surgery. These results suggest the value of burr hole surgery followed by ICP monitoring in patients with severe ASDH. Craniotomy can be performed safely using this method, and this may contribute to improved outcomes.

Objective: Because of an aging society, the incidence of chronic subdural hematoma (CSDH) is increasing. This lesion is treated with simple burr hole irrigation, but one of the major issues is that CSDH frequently recurs. ABO blood type may be associated with a bleeding tendency and inflammation. However, its association with the recurrence of CSDH remains unknown. Therefore, the authors of the present study aimed to retrospectively investigate the association between ABO blood type and CSDH recurrence., Methods: The authors retrospectively analyzed symptomatic CSDHs in 425 cerebral hemispheres of 376 patients who had undergone surgical treatment with irrigation of the hematoma via burr holes at their institution from January 2011 to September 2019. Among these were 366 CSDHs in 320 patients whose ABO blood type had been determined and who were included in this study., Results: In the study, 307 patients with CSDHs in 350 hemispheres were followed up postoperatively until the disappearance of the CDSH or for at least 3 months. Recurrence of CSDH was observed in 37 patients (10.6%) after surgical treatment. Blood type A was found to be significantly associated with CSDH recurrence compared to non-A blood types: 24 of 153 CDSHs (15.7%) versus 13 of 197 CDSHs (6.6%) (p = 0.008). In the multivariable regression analysis, blood type A, in addition to thrombocytopenia, was a significant independent predictor of the recurrence of CSDH., Conclusions: The study results showed that blood type A is an independent risk factor for the postoperative recurrence of CSDH and that careful follow-up in these patients may be needed.