Elsevier

World Neurosurgery

Volume 130, October 2019, Pages e133-e139
World Neurosurgery

Original Article
Risk Factors Predicting Recurrence of Bilateral Chronic Subdural Hematomas after Initial Bilateral Evacuation

https://doi.org/10.1016/j.wneu.2019.06.016Get rights and content

Background

Most patients with bilateral chronic subdural hematomas (bCSDH) undergo initial bilateral evacuation. Risk factors associated with the recurrence of bCSDH after initial bilateral evacuation have not been published to date. In this study, we aimed to identify risk factors related to recurrence of bCSDH after initial bilateral evacuation, and to develop a prognostic grading system for clinical reference.

Methods

This study included 102 patients with bCSDH who underwent initial bilateral evacuation. Predictors of recurrence were identified via univariate analysis and multivariate logistic regression analysis. A prognostic grading system was created based on the independent predictors combined with a cutoff value. All cases were scored according to the prognostic grading system, and the recurrence rates of the different scores were reanalyzed.

Results

Anticoagulant use (odds ratio [OR], 84.266; 95% confidence interval [CI], 13.113–541.522; P < 0.001), severe brain atrophy (OR, 11.551; 95% CI, 2.558–52.163; P = 0.001), and postoperative pneumocephalus volume (PostPV) (OR, 0.978; 95% CI, 0.957–1.000; P = 0.049) were independent risk factors for the recurrence of bCSDH after initial bilateral evacuation. The cutoff value of PostPV was >20.9484 cm3. A prognostic grading system was then developed, and the recurrence rates based on score were determined. Rates were 2.8% for a score of 0–1, 28.1% for a score of 2–3, and 100% for a score of 4–5, showing a significant increase in risk with increasing score (P < 0.001).

Conclusions

Anticoagulant use, severe brain atrophy, and PostPV were identified as independent risk factors for recurrence of bCSDH after initial bilateral evacuation. The prognostic grading system for recurrence of bCSDH after initial bilateral evacuation is reliable and applicable for clinical reference.

Introduction

Chronic subdural hematoma (CSDH) is a frequently encountered posttraumatic disorder. Especially prevalent among the elderly, CSDH affects 8.2–17.6 per 100,000 individuals annually and the incidence increases with population ages.1, 2, 3 Patients with CSDH are usually considered for surgical evacuation. Between 3% and 33% of patients experience rebleeding after the initial operation.2

Numerous risk factors have been shown to contribute to the recurrence of CSDH after surgical treatment, including age,4 anticoagulant or antiplatelet use,5, 6 midline shift,5, 7 preoperative hematoma size,5, 7, 8 postoperative pneumocephalus,9 postoperative hematoma residual,4, 7, 8 cranial computed tomography (CCT) density,8, 10 and bilateral hematomas.6, 11, 12 The decision to evacuate on a single side or both sides of bilateral chronic subdural hematoma (bCSDH) is generally based on hematoma size, mass effect, and lateralized clinical symptoms.13, 14 Most patients with bCSDHs undergo initial bilateral evacuation; however, the risk factors associated with recurrence of bCSDH after initial bilateral evacuation have not been published to date.

We therefore focused this retrospective analysis on identifying risk factors related to recurrence of bCSDH after initial bilateral evacuation, and on developing a grading system based on the independent risk factors, which can be applied as a clinical reference.

Section snippets

Patients and Clinical Parameters

This retrospective study included 102 consecutive patients with bCSDH who were admitted to Yijishan Hospital, Anhui Province, China, between November 2012 and October 2018. All patients underwent initial bilateral evacuation under general or local anesthesia. Subdural hematoma on each side was defined as a single case. All patients with bCSDH were diagnosed using CCT. Patients age <18 years, those with bCSDH caused by vascular disorder, and those who had undergone other intracranial surgery

Baseline Patient Characteristics

The study cohort comprised 23 women (22.55%) and 79 men (77.45%), ranging in age 40 to 90 years (mean age, 70.76 years). Head trauma was observed in 49 patients (48.04%); the average interval between the initial operation and trauma was 53.8 days. Six patients had received preoperative antiplatelet therapy, and 5 patients had received preoperative anticoagulant therapy. Headache was observed in 45 patients, motor weakness in 54 patients, hemiplegia in 19 patients, and altered consciousness in

Discussion

For bCSDH, there are no uniform indications for unilateral evacuation or bilateral evacuation. The decision for initial surgical evacuation on 1 side or both sides was generally based on the hematoma volume, lateralized clinical symptoms, and radiologic clues such as brain shift, subfalcial herniation, compressed ventricles, and compressed gyri and sulci. In previous study, we identified the volumes of the contralateral hematoma both before and after surgery as risk factors for contralateral

Conclusions

In this study, we have identified anticoagulant use, severe brain atrophy, and PostPV as independent risk factors for recurrence of bCSDH after initial bilateral evacuation. By combining the independent risk factors and cutoff value of PostPV, we have developed a reliable and applicable prognostic grading system that be used as a clinical reference.

Acknowledgments

We thank the Radiology Department for their help with radiologic parameters measurements.

References (21)

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Cited by (20)

  • The Danish Chronic Subdural Hematoma Study—Risk Factors for Second Recurrence

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    Though theoretically plausible, we did not find that patients with re-re-CSDH had shorter time until evacuation of their re-CSDH than patients with re-CSDH who did not develop a re-re-CSDH. Risk factors of recurrence have been thoroughly investigated and found to be influenced by several factors including operative technique, age, anticoagulants, volume of drainage, midline shift, brain atrophy, postoperative pneumocephalus, large postoperative subdural space, and poor preoperative performance status.12-15 These studies, including our own, investigate risk factors at the macroscopic level only.

  • Implementation of irrigating drainage systems after burr hole evacuation of bilateral subdural hematomas leads to reduction in postoperative pneumocephalus and improved brain re-expansion – A case report

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    A recent article by Jang et al. on 291 patients with cSDH that underwent burr hole evacuation found that persistently depressed brain volume 7 days after SDH evacuation is an independent factor that predicts hematoma recurrence (22% vs. 2.7% recurrence in brain volume depression greater than vs. <50 cm3; p < 0.001).23 Postoperative pneumocephalus is associated with cSDH recurrence after evacuation,25–28 and one paper found it specifically predicts increase in bilateral cSDH recurrence (OR 0.978; 95% CI, 0.957–2.000; P = 0.049).26 Irrigation may reduce pneumocephalus,19 and several studies demonstrate lower hematoma recurrence with irrigation, which is theorized to be due to displacement of air within the intracranial cavity with irrigation fluid that is then drained out.10,18,29

  • Reliability of an Automated Computerized Hematoma Volumetric Analysis Protocol in Patients with Chronic Subdural Hemorrhage

    2021, World Neurosurgery
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    In this study we have demonstrated high inter- and intraobserver reliability of a novel protocol for accurate and efficient volume measurement of CSDH. CSDH volume is directly related to the severity of symptoms and risk of recurrence after surgical evacuation, and therefore plays an important role in therapeutic decision-making.4,17,18 Most clinicians are accustomed to measuring thickness of clot on most prominent axial CT slice and midline shift as a surrogate for volumetric assessment of CSDH for decision-making purposes.19

  • Subdural Drain versus Subdural Evacuating Port System for the Treatment of Nonacute Subdural Hematomas: A Single-Center Retrospective Cohort Study

    2020, World Neurosurgery
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    It did affect whether an intervention in the operating room under general anesthesia was chosen instead, which is not investigated in this study. Some believe that subacute or chronic SDH in combination with significant cerebral atrophy presents a higher likelihood of recurrence for SDH,26-30 because of the lack of tamponade effect secondary to brain re-expansion after evacuation. Multiple other studies have suggested the contrary,16,18,25,31,32 although the data are inconclusive.

  • Comparison of Clinical and Radiologic Characteristics and Prognosis of Patients with Chronic Subdural Hematoma with and without a History of Head Trauma

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    PreHV, PostHV, and PostPV were calculated as volume = ∑ [area of each layer × layer thickness]. The area was measured using ImageJ software (National Institutes of Health, Bethesda, Maryland, USA).15,16 A uniform surgical procedure was performed to treat all hematomas in our study.

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Conflict of interest statement: This study was supported by grants from Collegiate Major Natural Science Research Projects (Grants KJ2017A267 and KJ2018ZD027, Anhui Province, China).

Ethical statement: This retrospective study does not involve patients' privacy, and thus formal consent was not required.

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