Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia.

OBJECTIVE: To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS: A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS: Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS: Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Tranexamic Acid in Chronic Subdural Hematomas (TRACS): study protocol for a randomized controlled trial.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most frequent reason for cranial neurosurgical consultation. There is no widely accepted medical treatment for this condition. Herein, we present the protocol for the Tranexamic Acid (TXA) in Chronic Subdural Hematomas (TRACS) trial aiming at determining whether TXA can increase the rate of CSDH resolution following conservative management, lower the number of required surgical procedures and decrease the rate of CSDH recurrence following surgical evacuation. METHODS: TRACS is a multicenter, double-blind, randomized, parallel-design, placebo-controlled, phase IIB study designed to provide preliminary efficacy data as well as feasibility, safety and incidence data required to plan a larger definitive phase III trial. Consecutive patients presenting with a diagnosis of chronic subdural hematoma will be screened for eligibility. Exclusion criteria include: specific risk factors for thromboembolic disease, anticoagulant use or contraindication to TXA. A total of 130 patients will be randomized to receive either 750 mg of TXA daily or placebo until complete radiological resolution of the CSDH or for a maximum of 20 weeks. CSDH volume will be measured on serial computed tomography (CT) scanning. Cognitive function tests, quality of life questionnaires as well as functional autonomy assessments will be performed at enrollment, at 10 weeks following randomization and at 3 months following treatment cessation. During the treatment period, patients will undergo standard CSDH management with surgery being performed at the discretion of the treating physician. If surgery is performed, the CSDH and its outer membrane will be sampled for in vitro analysis. The primary outcome is the rate of CSDH resolution by 20 weeks without intervening unplanned surgical procedure. Secondary outcomes include: CSDH volume, incidence of surgical evacuation procedures, CSDH recurrence, cognitive functions, functional autonomy, quality of life, incidence of complications and length of hospital stay. Planned subgroup analyses will be performed for conservatively versus surgically managed subjects and highly versus poorly vascularized CSDH. DISCUSSION: CSDH is a frequent morbidity for which an effective medical treatment has yet to be discovered. The TRACS trial will be the first prospective study of TXA for CSDH. TRIAL REGISTRATION: NCT ID: NCT02568124 .

[Chronic subdural hematoma and psychotic decompensation]. / Hématome sous-dural chronique et décompensation psychotique.

BACKGROUND: In Tunisia, with the remarkable progress in health, life expectancy has significantly increased these last decades. Indeed, in 2004, 9.3% of the population was aged over 60, and this rate is predicted to reach 17% in 2029 and about 29% by 2050. In the elderly, chronic subdural hematoma (HSDC) may be caused by even minimal trauma or occur spontaneously. The manifestations of this type of accumulation depend on the degree of cerebral compression and the localisation of the mass. They could be delirium, dementia, convulsions or psychiatric disorders (frontal location). CASE REPORT: When the psychiatric presentation predominates, the decision to hospitalise an elderly person in a psychiatric unit is difficult and often avoided. We report the case of an 81 year-old man without history of medical condition or personal or family psychiatric history, who, in 2000, began to exhibit behavioural disorders, delusions of persecution and jealousy, visual hallucinations and sexual disinhibition. This clinical picture that set in so insidiously and in moderate intensity was long tolerated by the family circle. The patient was admitted to a psychiatric hospital in January 2008 with the worsening of the symptoms. The clinical examination and investigations confirmed the diagnosis of chronic frontoparietal subdural hematoma without compression. The decision in neurosurgery was to refrain from surgical drainage and administer high doses of steroids under supervision (clinical and biological). The evolution was good with progressive resorption of the hematoma to complete recovery. Currently, the patient is symptom free and the last CT scan on 03/11/2010 confirms the total resorption of the hematoma. CONCLUSION: It appears from this case and review of the literature that various psychiatric manifestations may reveal an HSDC and that, in the elderly, neuroimaging should be systematic, even for minor symptoms. The total resorption led to the disappearance of psychiatric symptoms in most patients, but this remains a topic of discussion for patients who retain residual symptoms, even after resorption of the mass. Caution is required when faced with an elderly person suffering, and we should strive to explore all possible causes before jumping to the conclusion of the fatality of growing old.

Twist drill craniostomy with closed drainage for chronic subdural haematoma in the elderly: an effective method.

OBJECTIVE: Chronic subdural haematoma is a disease of the elderly and surgery in these patients carries a much higher risk. The common surgical procedures for chronic subdural haematoma include twist drill craniostomy, burr hole evacuation or craniotomy. The aim of this study was to analyse the results of twist drill craniostomy with drainage in elderly patients with chronic subdural haematoma. METHODS: Forty-two elderly patients (>65 years) with radiologically proven chronic subdural haematoma were analysed. All the patients underwent twist drill craniostomy and continuous drainage of the haematoma under local anaesthesia and total intravenous anaesthesia (TIVA). RESULTS: There were 24 males and 18 females. Headache and cognitive decline was seen in 50% and weakness of limbs in 60% of patients. CT scan was done in all cases. All patients underwent twist drill 2-3 cm in front of the parietal eminence under local anaesthesia. The drain was left for 24-72 h depending on the drainage. At 1 week, 88% of patients had a good outcome. CONCLUSION: Twist drill craniostomy with drainage under local anaesthesia is a safe and effective procedure for chronic subdural haematoma in the elderly and could be used as the first and only option in these people.

[Subdural hematoma and depression]. / Subduraal hematoom en depressie.

BACKGROUND: Chronic subdural haematoma (csdh) is difficult to diagnose because patients with this disorder, in particular the elderly, present with such a wide variety of symptoms. The subject of this case study is an 89-year-old man with a history of csdh who presented with severe depressive symptoms with psychotic features and who in the end turned out to have a recurrence of csdh. An integrated past and who present with psychiatric problems and fall frequently. When a patient presents with such symptoms, one needs to be on the look-out for a recurrence of csdh.

Can midline brain shift be used as a prognostic factor to predict postoperative restoration of consciousness in patients with chronic subdural hematoma?

BACKGROUND AND PURPOSE: Our aim was to determine if midline brain shift could be used as a prognostic factor to predict postoperative restoration of consciousness in patients with CSDH. In these patients, we evaluated the relation (1) between midline brain shift as measured on CT and alteration of level of consciousness, and (2) between midline brain shift and restoration of consciousness after the operation. METHODS: Prospectively recorded data of 45 patients with CSDH were evaluated. We compared level of consciousness of patients measured by GCS score, brain displacement at PG and SP both in the preoperative and early postoperative period. RESULTS: Preoperatively, PG and SP shifts of the patients who were alert (GCS = 15) were significantly less than those of patients who had diminished consciousness. However, in patients with diminished consciousness (GCS < 15), the amount of lateral brain displacement and the degree of diminution of consciousness did not correlate. Those patients who had a preoperative SP shift of less than 10 mm had a significantly lesser chance to become alert after operation (2 of 5 patients) when compared with those patients who had a preoperative SP shift of 10 mm or more (21 of 23 patients). CONCLUSIONS: We conclude that preoperative SP shift may be used as a factor to predict restoration of consciousness in patients with CSDH; the likelihood of becoming alert after operation is increased if SP shift is 10 mm or greater, and is decreased if SP shift is less than 10 mm.

[Chronic subdural hemorrhage in a patient with suspected schizophrenia prodrome]. / Chronisch subdurales Hämatom bei einem Patienten mit Verdacht auf Prodromalstadium einer Schizophrenie.

A patient showing "prodromal symptoms" of suspected psychosis was referred to our clinic specialized in early recognition of schizophrenia where an MRI brain scan showed a chronic subdural hemorrhage. Based on this case, it will be shown that organic brain disease, in addition to incipient schizophrenia, needs to be considered in patients with marked personality changes, social withdrawal, aggressiveness, and suspiciousness. Diagnosis of the first episode and prodromal stage of schizophrenia should include-apart from the case history as well as the psychopathological and physiological findings-certain obligatory medical examinations (EEG, cCT, or MRI) in order to identify possible organic causes and avoid misdiagnoses.

Unilateral spatial neglect associated with chronic subdural haematoma: a case report.

A 69-year-old right-handed man who exhibited unilateral spatial neglect in association with a chronic subdural haematoma, presented with mild left arm and leg weakness first noted 4 weeks prior to admission. Neurologic examination on admission revealed a mild left hemiparesis, including the face. Neuropsychologic examination revealed left unilateral spatial neglect, but no language disturbance. Minimal support was necessary to maintain activities of daily living. Computed tomography revealed a large right temporoparietal, extraaxial hypodense fluid collection containing scattered hypodense foci. The haematoma was evacuated via a right parietal burr hole. Following surgery, the patient dramatically improved neurologically and neuropsychologically, as well as in independent performance of daily activities. It is suggested that the improvement in ADL provides a behavioural correlate of improvement in the latter, represented a behavioural correlate of improved cerebral function, and that either direct compression by the chronic subdural haematoma or an interhemispheric pressure difference had caused unilateral spatial neglect. Such neglect is an unusual consequence of chronic subdural haematoma.

[Chronic subdural hematoma with psychopathological manifestations]. / Przewlekly krwiak podtwardówkowy z manifestacja psychopatologiczna.

A seventy-one-year old male patient was consulted by psychiatrist at the request of family physician on account of growing dementia. The first examination revealed deteriorated verbal contact, deficiency of memory and intellect and problems with sense of locality. Neither hallucinations nor delusions were found. However, after a detailed examination it was established that deterioration in verbal contact was due to aphasia and not dementia. Also, right side hemiparesis of small degree was detected. In spite of these symptoms the patient was able to move by himself. After admission to neurological department, computer tomography of brain was performed. It showed big subdural hematoma whose size was 13.2 by 2.9 cm. Adequate surgery was carried out and the patient was discharged from hospital ten days after operation. During supervisory examination, performed two months after intervention, no psychopathological problems were found. Also, deficiencies of memory, intellect and concentration were normal for the patient's age. The presented instance is a good argument for thorough examination of mental and neurological state, even in apparently evident cases. This description is illustrated with two tomograph pictures of brain.