Successful Management of Acute Subdural Hematoma in Deep Brain Stimulation Patient: A Case Report and Literature Review.

Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.

Craniectomy versus craniotomy: What can we do for acute subdural hematoma?

Compared with hematoma evacuation craniotomy, decompressive craniectomy has a higher incidence of intracranial complications and no outcome benefit over craniotomy, which gives surgeons a safer decision-making options during surgery.

Endoscopic Evacuation of Acute Subdural Hematomas: A New Selection Criterion.

Introduction Acute subdural hematomas (ASDHs) have a high mortality rate and unfavorable outcomes especially in the elderly population even after surgery is performed. The conventional recommended surgeries by the Brain Trauma Foundation in 2006 were craniotomies or craniectomies for ASDH. As the world population ages, and endoscopic techniques improve, endoscopic surgery should be utilized to improve the outcomes in elderly patients with ASDH. Materials and Methods This was a single-center retrospective report on our series of six patients that underwent endoscopic ASDH evacuation (EASE). Demographic data, the contralateral global cortical atrophy (GCA) score, evacuation rates, and outcomes were analyzed. Results All patients' symptoms and Glasgow Coma Scale improved or were similar after EASE with no complications. Good outcome was seen in 4 (66.7%) patients. Patients with poor outcome had initial low Glasgow Coma Scale scores on admission. The higher the contralateral GCA score, the higher the evacuation rate ( r = 0.825, p ≤ 0.043). All the patients had a GCA score of ≥7. Conclusion EASE is at least not inferior to craniotomy for the elderly population in terms of functional outcome for now. Using the contralateral GCA score may help identify suitable patients for this technique instead of just using a cut-off age as a criteria.

Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS: From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS: Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS: The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.

Assessment of cerebrovascular alterations induced by inflammatory response and oxidative-nitrative stress after traumatic intracranial hypertension and a potential mitigation strategy.

The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood-brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative-nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Acute subdural hematoma caused by hemorrhagic falx meningioma: A case report and review of the literature.

We herein report a case of acute subdural hematoma caused by hemorrhagic falx meningioma. The patient was a 64-year-old woman with no significant medical history or prior history of trauma. She experienced a sudden onset of headache and weakness in her extremities. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed a mass lesion with intratumoral hemorrhage or faint calcification along the left side of the fronto-parietal cerebral falx. There was also a linear lesion at the left side of the falx, suggesting acute subdural hematoma. MRI was performed again on the eleventh day. On precontrast T1-weighted images, intratumoral hemorrhage and widespread left subdural hematoma were shown as high intensity. On postcontrast T1-weighted images, the tumor showed heterogeneous enhancement with a dural tail sign on the falx, indicative of a falx meningioma. She underwent surgical resection, and the histological subtype was transitional meningioma. Nine cases of hemorrhagic falx meningioma associated with acute subdural hematoma have been reported. If not limited to the site of occurrence, there have been 59 reported cases overall. In our investigation, the incidence of hemorrhage is higher in the convexity and lower in the skull base. It is higher for fibrous, angiomatous, and metaplastic subtypes and lower for meningothelial subtype. The location and histological subtype might be risk factors for meningioma associated with subdural hematoma. Further accumulation of cases will be necessary to establish the cause of bleeding.

Decompressive craniotomy in split-technique (DCST) for TBI in infants: introducing a new surgical technique to prevent long-term complications.

INTRODUCTION: Decompressive craniectomy (DC) is rarely required in infants. These youngest patients are vulnerable to blood loss, and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. MATERIAL AND METHODS: We propose a new technique called DCST, which makes use of these unique aspects by achieving decompression using the circumstance of the thin and flexible bone. We describe the surgical technique and the follow-up course over a period of 13 months. RESULTS AND CONCLUSION: In our study, DCST achieved adequate decompression and no  further repeated surgeries in accordance with decompressive craniectomy were needed afterwards.

Delayed Manifestation of Massive Bilateral Sub-acute Subdural Hemorrhage.

Sub-acute subdural hematoma (SASDH) in the elderly is a challenging diagnosis given its insidious onset and nonspecific presentation, particularly following minor head trauma. This case report highlights the clinical features, diagnostic challenges, and management of SASDH in an elderly patient. A 72-year-old male presented with a five-day history of giddiness, headache, and balance issues, which began suddenly without a significant triggering event. His medical history was notable only for a minor fall approximately one month before presentation, after which he experienced no immediate or significant symptoms. An MRI at an outside hospital revealed bilateral frontoparietotemporal SASDHs with diffuse cerebral edema. The patient underwent a bilateral mini craniotomy for hematoma evacuation and was managed postoperatively with anti-seizure medications and supportive care, resulting in a satisfactory outcome. The diagnosis of SASDH requires a high index of suspicion, especially in the elderly, who may present with vague and progressive symptoms following minor head trauma. Early and accurate diagnosis via imaging, particularly MRI, is crucial for effective management. Surgical intervention, typically involving hematoma evacuation, significantly improves outcomes in patients with SASDH, underscoring the importance of timely surgical referral and treatment. Elderly patients presenting with unexplained neurological symptoms following even minor trauma should be evaluated for SASDH. Early recognition and intervention are crucial to prevent long-term morbidity and mortality in this vulnerable population.

Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report.

PURPOSE: Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION: An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION: TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Fatal convexity and interhemispheric acute subdural hematoma from a falx meningioma: A case report.

Background: Hemorrhagic meningiomas are rare. We report a rare case of nontraumatic convexity and interhemispheric acute subdural hematoma (ASDH) caused by a falx meningioma. Case Description: An 84-year-old woman with a history of atrial fibrillation and hypertension who was taking warfarin presented to our emergency department with a sudden disorder of consciousness. The patient had no traumatic events associated with her symptoms. Computed tomography (CT) revealed right convexity and interhemispheric ASDH, mass lesions in the left frontal lobes, and brain herniation. Contrast-enhanced CT revealed vascular structures within the mass lesion. CT angiography (CTA) revealed no aneurysm or arteriovenous malformation, and the venous phase revealed occlusion in the anterior portion of the superior sagittal sinus. The patient had her right convexity and interhemispheric ASDH removed endoscopically. A mass lesion located on the falx, which was easily bleeding, soft, and suctionable, was immediately detected. Histopathological examination revealed fibrous meningioma, a benign meningioma of the World Health Organization grade 1. Despite undergoing aggressive treatment, the patient's general condition deteriorated. Conclusion: Hemorrhagic meningiomas can easily be missed with plain CT, and the enhancement effect of CTA and tumor shadow on digital subtraction angiography may not be observed during the acute phase. Surgery for nontraumatic ASDH should be performed considering the possibility that a meningioma causes it.

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma.

INTRODUCTION: The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH. MATERIALS AND METHODS: All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated. RESULTS: In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001). CONCLUSION: If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis.

Introduction: Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making. Methods: Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model. Results: The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure. Conclusion: The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

Incidence, risk factors, and clinical outcomes of acute brain swelling associated with traumatic acute subdural hematoma: a retrospective study utilizing novel diagnostic criteria.

Background: Post-traumatic acute brain swelling (ABS) is a major cause of elevated intracranial pressure and thus mortality. The current definition of post-traumatic ABS has certain limitations, and there is limited information available regarding ABS associated with traumatic acute subdural hematoma (ASDH). Objectives: To investigate the incidence, risk factors, and clinical outcomes of ABS associated with traumatic ASDH. Design: Retrospective study. Methods: Data for 161 patients diagnosed with traumatic ASDH were retrospectively collected. Novel computed tomography-based criteria were proposed for diagnosing ABS in patients with ASDH and determining its incidence. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of post-traumatic ABS. The Glasgow Outcome Scale (GOS) score, mortality, and functional prognosis of all patients at discharge and the proportion of intraoperative malignant brain bulge in surgical patients were taken as clinical outcome measures. Results: A total of 45 (28%) patients experienced post-traumatic ABS, exhibiting significantly lower Glasgow Coma Scale scores on admission (p < 0.001). The incidence of hemispheric and whole-brain swelling was 8.1% and 19.9%, respectively. Risk factors independently associated with post-traumatic ABS were: (1) age [odds ratio (OR) = 0.917, p < 0.001]; (2) platelet to white blood cell ratio (PWR) (OR = 0.887, p = 0.012); and (3) traumatic subarachnoid hemorrhage (SAH) (OR = 4.346, p = 0.005). The ABS cohort had a lower GOS score [2 (1-3) versus 4 (3-5); p < 0.001], higher mortality (46.7% versus 6.9%; p < 0.001), and higher proportion of unfavorable functional prognosis (75.6% versus 34.5%; p < 0.001) upon discharge compared to the no ABS cohort, along with higher proportion of intraoperative malignant brain bulge (43.8% versus 0%; p < 0.001). Conclusion: The incidence of ABS associated with ASDH is significantly high overall. Patients with ASDH who have young age, low PWR, and traumatic SAH are at an increased risk of developing post-traumatic ABS, and therefore of poor clinical outcomes.

The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas.

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/µL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).

Interhemispheric Acute Subdural Hematoma Secondary to Falx Meningioma: A Case Report.

This report describes an unusual case of falx meningioma associated with acute subdural hematoma, which is a rare presentation. A 76-year-old woman presented with right-sided hemiparesis and a known falx meningioma that had rapidly increased in volume over the previous year. Computed tomography revealed interhemispheric and left-hemispheric acute subdural hematomas. Preoperative embolization and surgical tumor removal were performed to improve the symptoms, and pathological examination of the tumor revealed transitional meningioma (WHO Grade I). The patient's paresis symptoms improved postoperatively. This report provides valuable insights into the management and outcomes of falx meningioma with acute subdural hematoma, suggesting aggressive surgery to improve postoperative recovery.

Convexity Dural Arteriovenous Fistula without Cortical Venous Reflux Presenting with Pure Acute Subdural Hematoma.

Hemorrhagic changes in a dural arteriovenous fistula are typically associated with cortical venous reflux and occur as intracerebral or subarachnoid hemorrhages. A convexity dural arteriovenous fistula (DAVF) usually flows directly into the cortical veins and exhibits cortical venous reflux. Herein, we report a rare case of a convexity DAVF without cortical venous reflux presenting with a pure acute subdural hematoma. A 19-year-old man complaining of headache without any history of head injury was diagnosed with a left acute subdural hematoma on magnetic resonance imaging (MRI) and referred to our hospital. The patient was conscious and exhibited no neurological signs. The MRI did not reveal any possible abnormalities leading to hemorrhage. Cerebral angiography revealed a dural arteriovenous fistula in the left parietal cranium with a feeder from the middle meningeal artery and a drainer into the main transverse sinus via a diploic vein. Part of the shunt blood flowed into the superior sagittal sinus from the meningeal vein; however, there was no reflux into the cortical vein or stasis of the cerebral vein, suggesting venous hypertension. A convexity DAVF was diagnosed as the source of bleeding, and transarterial embolization was performed. The patient recovered without any neurological deficits. In the absence of trauma, an acute subdural hematoma requires an appropriate evaluation of the vascular lesions and a treatment plan.

The spectrum of acute and chronic consequences of neurotrauma in professional and amateur boxing - A call to action is advocated to better understand and prevent this phenomenon.

Introduction: Despite changes in regulations, boxing-related injuries and fatalities are still occurring. The numbers available in the literature regarding mortality and long-term consequences may not accurately represent the actual situation. Indeed, the real extent of this phenomenon remains poorly known. Research question: Delineating the spectrum of acute and chronic consequences of boxing-related traumatic brain injuries (TBI). Material and methods: Narrative review of the literature concerning acute and chronic boxing-related TBI. Keywords such as mortality, boxing, subdural hematoma were used to search in PubMed and Google scholar. An updated analysis of the Velazquez fatalities collection in boxing was undertaken. Results: The Velazquez collection includes 2076 fatalities from 1720 to the present with a death rate of 10 athletes per year. More than half of the deaths (N = 1354, 65.2%) occurred after a knock-out, and nearly 75% happened during professional bouts. In Australia, from 1832 to 2020, 163 fatalities were recorded (75% professional). In Japan, from 1952 to 2016, 38 deaths were recorded with a mean age of 23.9 years. Up to 40% of retired professional boxers in the United States were diagnosed with symptoms of chronic brain injury. Clinical dementia is far more prevalent among professional boxers than in amateurs with an incidence of 20%. Discussion and conclusions: A concerted effort to raise awareness and shed light on boxing-related neuro-trauma is required. Similar considerations can be made for other combat sports or contact sports. A call to action to address this knowledge gap, decrease and prevent this phenomenon is advocated.

Influence of Blood Components on Neuroinflammation, Blood-Brain Barrier Breakdown, and Functional Damage After Acute Subdural Hematoma in Rats.

A central component of injury development after acute subdural hematoma (ASDH) is the increased intracranial pressure and consecutive mechanical reduction of cerebral blood flow (CBF). However, the role of different blood constituents in ASDH as additional lesioning factors remains unclear. This study examines the influence of blood components on neuroinflammation, blood-brain barrier (BBB) breakdown, and functional deficits in a rat model of ASDH. We infused corpuscular (whole blood, whole blood lysate, and red cell blood) and plasmatic (blood plasma, anticoagulated blood plasma, and aqueous isotonic solution) blood components into the subdural space while CBF was monitored. Rats then underwent behavioral testing. Lesion analysis and immunohistochemistry were performed 2 days after ASDH. Inflammatory reaction was assessed using staining for ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein, interleukin-1ß, tumor necrosis factor-alpha, and membrane attack complex. Integrity of the BBB was evaluated with albumin and matrix metalloproteinase 9 (MMP9) staining. We observed a significant drop in CBF in the corpuscular group (75% ± 7.5% of baseline) with distinct post-operative deficits and larger lesion volume compared to the plasmatic group (13.6 ± 5.4 vs. 1.3 ± 0.4 mm3). Further, inflammation was significantly increased in the corpuscular group with stronger immunoreaction. After whole blood infusion, albumin and MMP9 immunoreaction were significantly increased, pointing toward a disrupted BBB. The interaction between corpuscular and plasmatic blood components seems to be a key factor in the detrimental impact of ASDH. This interaction results in neuroinflammation and BBB leakage. These findings underscore the importance of performing surgery as early as possible and also provide indications for potential pharmacological targets.