Efficacy analysis of flexible neuroendoscopy combined with dry-field techniques in the treatment of chronic subdural hematoma.
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ABSTRACT:
SUBMITTER: Guan F
PROVIDER: S-EPMC6629348 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
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Efficacy analysis of flexible neuroendoscopy combined with dry-field techniques in the treatment of chronic subdural hematoma.
Guan Feng F Peng Wei-Cheng WC Huang Hui H Dai Bin B Zhu Guang-Tong GT Xiao Zhi-Yong ZY Mao Bei-Bei BB Lin Zhen-Yang ZY Zhou Quan Q Wei Ya-Ping YP Hu Zhi-Qiang ZQ
Chinese medical journal 20190601 11
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Project description:Background: Several pharmacological treatments have been used to treat patients with chronic subdural hematoma (CSDH), although little is known about the comparative effectiveness of different classes of medication. We performed a Bayesian network meta-analysis to compare and rank the efficacy and safety of five drug regimens to determine the best treatment for this group of patients. Methods: We systematically searched PubMed, Medline, clinicaltrials.gov, the Cochrane database, and Embase to identify relevant randomized clinical trials (RCTs) comparing drug treatments in adult patients with CSDH. A network meta-analysis was conducted using a Bayesian framework. Random- and fixed-effects models were used to pool the network results, and the preferred model was selected by comparing the deviance information criteria (DIC). Efficacy outcomes included recurrence requiring surgery, changes in hematoma volume, and a good recovery. The safety outcomes were treatment-related adverse events and all-cause mortality. Results: In this Bayesian network meta-analysis, available data were obtained from 12 eligible trials, including 2,098 patients and 5 techniques. Compared to placebo, atorvastatin (RR: 0.45, 95% CrI: 0.24-0.81) and dexamethasone (RR: 0.38, 95% CrI: 0.22-0.63) were similarly effective in reducing recurrence requiring surgery by 55% and 62%, respectively. Dexamethasone (RR: 0.46, 95% CrI: 0.23-0.91) was more effective in reducing recurrence requiring surgery than goreisan. Additionally, atorvastatin reduced the hematoma volume to a greater extent than placebo (MD: -7.44, 95% CrI: -9.49 to -5.43) or goreisan (MD: -14.09, 95% CrI: -23.35 to -4.82). Moreover, tranexamic acid (MD: -12.07, 95% CrI: -21.68 to -2.29) reduced the hematoma volume to a greater extent than goreisan. No significant differences were detected between drugs and placebo with regard to a good recovery. In terms of safety, dexamethasone (RR: 1.96, 95% CrI: 1.20-3.28) increased the risk of mortality compared to placebo. Conclusion: These findings suggest that dexamethasone is the best treatment to reduce recurrence and atorvastatin is the best treatment to reduce hematoma volume in patients with CSDH. However, clinicians should pay close attention to the elevated risk of all-cause mortality and potential adverse events caused by dexamethasone. Future well-designed RCTs with more participants are needed to verify these findings. Clinical Trial Registration: http://osf.io/u9hqp.
| S-EPMC8280518 | biostudies-literature
Project description:BackgroundChronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH.MethodsElectronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114).ResultsThe NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs.ConclusionDBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe.Systematic review registrationhttps://inplasy.com/inplasy-2023-2-0114/.
| S-EPMC10411900 | biostudies-literature
Project description:The levels of angiogenic factors were analyzed in eight patients who underwent the embolization of chronic subdural hematoma (CSDH) with non-adhesive liquid embolic agents. Four of these patients had previously undergone surgical treatment for hematoma removal and had recurrences of a similar volume, and four had an increase in hematoma volume due to rebleeding. The levels of vascular endothelial growth factor (VEGF), matrix metallopeptidase 9 (MMP 9), angiopoietin-2 (Ang2), transforming growth factor beta 1 (TGF-β1) and platelet-derived growth factor BB (PDGF-BB) in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The levels of VEGF in the samples of all the patients were close to normal or slightly decreased. There was an increase in the MMP9 levels (the factor that contributes to the disintegration of the vessel wall components) in all the patients. The Ang2 and especially the PDGF TGF-β1 (the factor that plays an important role in the growth of the vessel wall from the already existing blood vessel tissue) levels were distinctly low in most of the cases and slightly elevated only in a number of patients who had previously been operated on. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. At the same time, the factors determining the formation of the vessel wall were reduced, and the levels of factors contributing to the degradation of extracellular matrix components were significantly increased. Such factors could help us to anticipate the increased risk of hemorrhages. Highlights: The levels of VEGF, MMP 9, Ang2, TGF-β1 and PDGF-BB in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. Such a profile of factors could help us to anticipate the increased risk of hemorrhages.
| S-EPMC9689028 | biostudies-literature
Project description:Background: Evidence suggests that hyperdense (HD) chronic subdural hematomas (CSDHs) have a higher recurrence than hypodense (LD) chronic subdural hematomas. The value of mean hematoma density (MHD) has been proven to be associated with postoperative recurrence. The MHD levels in homogeneous CSDHs likely underestimate the risk of recurrence in HD homogeneous subtypes. Methods: This study investigated 42 consecutive CSDH cases between July 2010 and July 2014. The area of the hematoma was quantified to determine the MHD level using computer-based image analysis of preoperative brain CT scans. Results: In terms of the MHD distribution of the four types of CSDHs (homogeneous, laminar, separated, and trabecular), wide 95% CI (11.80-16.88) and high standard deviation (4.59) can be found in homogeneous types, reflecting a high variability in the MHD levels between cases (from low to high density). The categorization of homogeneous types into LD and HD (type five) displayed a minor standard deviation in the MHD levels for LD and HD subtypes (1.15, and 0.88, respectively). MHD values demonstrated concentrated distributions among the respective five types, compared to the four-type setting. Conclusions: In the current research, we provide a consideration that if LD and HD hematomas are separated from homogeneous CSDHs, the variability of the MHD quantification can potentially be reduced, thereby avoiding the possibility of undetected high-risk groups.
| S-EPMC9689778 | biostudies-literature
Project description:Chronic subdural hematoma (cSDH), previously considered fairly benign and easy to treat, is now viewed a possible sign of incipient clinical decline. We investigated case-fatality, excess fatality and need for reoperations following operated cSDH in a nationwide setting focusing on patient-related characteristics. Finnish nationwide databases were searched for all admissions with operated cSDH as well as later deaths in adults (≥ 16 years) during 2004-2017. There were 8539 patients with an evacuated cSDH (68% men) with a mean age of 73.0 (± 12.8) years. During the follow-up, 3805 (45%) patients died. In-hospital case-fatality was 0.7% (n = 60) and 30-day case-fatality 4.2% (n = 358). The 1-year case-fatality was 14.3% (95% CI = 13.4-15.2%) among men and 15.3% (95% CI = 14.0-16.7%) among women. Comorbidity burden, older age, and alcoholism were significantly associated with fatality. One-year excess fatality rate compared to general Finnish population was 9.1% (95% CI = 8.4-9.9) among men and 10.3% (95% CI = 9.1-11.4) among women. Highest excess fatality was observed in the oldest age group in both genders. Reoperation was needed in 19.4% (n = 1588) of patients. Older age but not comorbidity burden or other patient-related characteristics were associated with increased risk for reoperation. The overall case-fatality and need for reoperations declined during the study era. Comorbidities should be considered when care and follow-up are planned in patients with cSDH. Our findings underpin the perception that the disease is more dangerous than previously thought and causes mortality in all exposed age groups: even a minor burden of comorbidities can be fatal in the post-operative period.
| S-EPMC9054845 | biostudies-literature
Project description:Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.
| S-EPMC9498240 | biostudies-literature
Project description:ObjectiveChronic subdural hematoma (CSDH) is a common neurological condition and is typically treated with burr hole craniostomy. Nevertheless, conservative treatment may lead to spontaneous hematoma resolution in some patients. This study aims to describe the characteristics of patients who were treated conservatively without the eventual need for additional treatment.MethodsData were retrospectively collected from patients who were primarily treated conservatively in three hospitals in the Netherlands from 2008 to 2018. The Primary outcome was the nonnecessity of additional treatment within 3 months after the initial CSDH diagnosis. We used univariable and multivariable logistic regression analyses to identify factors associated with not receiving additional treatment.ResultsIn this study, 83 patients were included and 61 patients (73%) did not receive additional treatment within 3 months. Upon first presentation, the patients had a Markwalder Grading Scale score (MGS) of 0 (n = 5, 6%), 1 (n = 43, 52%), and 2 (n = 35, 42%). Additional treatment was less often received by patients with smaller hematoma volumes (adjusted odds ratio [aOR] 0.78 per 10 mL; 95% confidence interval [CI] 0.64-0.92). Patients using antithrombotic medication also received less additional treatment, but this association was not significant (aOR 2.02; 95% CI 0.61-6.69).ConclusionsThree quarters of the initially conservatively treated CSDH patients do not receive additional management. Typically, these patients have smaller hematoma volumes. Further, prospective research is needed to distinguish which patients require surgical intervention and in whom primary conservative treatment suffices.
| S-EPMC11219291 | biostudies-literature
Project description:ImportanceChronic subdural hematoma (CSDH) is a trauma-associated condition commonly found in elderly patients. Surgery is currently the treatment of choice, but it carries a significant risk of recurrence and death. Nonsurgical treatments remain limited and ineffective. Our recent studies suggest that atorvastatin reduces hematomas and improves the clinical outcomes of patients with CSDH.ObjectiveTo investigate the safety and therapeutic efficacy of atorvastatin to nonsurgically treat patients with CSDH.Design, setting, and participantsThe Effect of Atorvastatin on Chronic Subdural Hematoma (ATOCH) randomized, placebo-controlled, double-blind phase II clinical trial was conducted in multiple centers in China from February 2014 to November 2015. For this trial, we approached 254 patients with CSDH who received a diagnosis via a computed tomography scan; of these, 200 (78.7%) were enrolled because 23 patients (9.1%) refused to participate and 31 (12.2%) were disqualified.InterventionsPatients were randomly assigned to receive either 20 mg of atorvastatin or placebo daily for 8 weeks and were followed up for an additional 16 weeks.Main outcomes and measuresThe primary outcome was change in hematoma volume (HV) by computed tomography after 8 weeks of treatment. The secondary outcomes included HV measured at the 4th, 12th, and 24th weeks and neurological function that was evaluated using the Markwalder grading scale/Glasgow Coma Scale and the Barthel Index at the 8th week.ResultsOne hundred ninety-six patients received treatment (169 men [86.2%]; median [SD] age, 63.6 [14.2] years). The baseline HV and clinical presentations were similar between patients who were taking atorvastatin (98 [50%]) and the placebo (98 [50%]). After 8 weeks, the HV reduction in patients who were taking atorvastatin was 12.55 mL more than those taking the placebo (95% CI, 0.9-23.9 mL; P = .003). Forty-five patients (45.9%) who were taking atorvastatin significantly improved their neurological function, but only 28 (28.6%) who were taking the placebo did, resulting in an adjusted odds ratio of 1.957 for clinical improvements (95% CI, 1.07-3.58; P = .03). Eleven patients (11.2%) who were taking atorvastatin and 23 (23.5%) who were taking the placebo underwent surgery during the trial for an enlarging hematoma and/or a deteriorating clinical condition (hazard ratio, 0.47; 95% CI, 0.24-0.92; P = .03). No significant adverse events were reported.Conclusions and relevanceAtorvastatin may be a safe and efficacious nonsurgical alternative for treating patients with CSDH.Trial registrationClinicalTrials.gov Identifier: NCT02024373.
| S-EPMC6248109 | biostudies-literature
Project description:Atorvastatin has been shown to be a safe and effective non-surgical treatment option for patients with chronic subdural hematoma. However, treatment with atorvastatin is not effective in some patients, who must undergo further surgical treatment. Dexamethasone has anti-inflammatory and immunomodulatory effects, and low dosages are safe and effective for the treatment of many diseases, such as ankylosing spondylitis and community-acquired pneumonia. However, the effects of atorvastatin and low-dose dexamethasone for the treatment of chronic subdural hematoma remain poorly understood. Hematoma samples of patients with chronic subdural hematoma admitted to the General Hospital of Tianjin Medical University of China were collected and diluted in endothelial cell medium at 1:1 as the hematoma group. Atorvastatin, dexamethasone, or their combination was added to the culture medium. The main results were as follows: hopping probe ion conductance microscopy and permeability detection revealed that the best dosages to improve endothelial cell permeability were 0.1 μM atorvastatin and 0.1 μM dexamethasone. Atorvastatin, dexamethasone, or their combination could markedly improve the recovery of injured endothelial cells. Mice subcutaneously injected with diluted hematoma solution and then treated with atorvastatin, dexamethasone, or their combination exhibited varying levels of rescue of endothelial cell function. Hopping probe ion conductance microscopy, western blot assay, and polymerase chain reaction to evaluate the status of human cerebral endothelial cell status and expression level of tight junction protein indicated that atorvastatin, dexamethasone, or their combination could reduce subcutaneous vascular leakage caused by hematoma fluid. Moreover, the curative effect of the combined treatment was significantly better than that of either single treatment. Expression of Krüppel-like factor 2 protein in human cerebral endothelial cells was significantly increased, as was expression of the tight junction protein and vascular permeability marker vascular endothelial cadherin in each treatment group compared with the hematoma stimulation group. Hematoma fluid in patients with chronic subdural hematoma may damage vascular endothelial cells. However, atorvastatin combined with low-dose dexamethasone could rescue endothelial cell dysfunction by increasing the expression of tight junction proteins after hematoma injury. The effect of combining atorvastatin with low-dose dexamethasone was better than that of atorvastatin alone. Increased expression of Krüppel-like factor 2 may play an important role in the treatment of chronic subdural hematoma. The animal protocols were approved by the Animal Care and Use Committee of Tianjin Medical University of China on July 31, 2016 (approval No. IRB2016-YX-036). The study regarding human hematoma samples was approved by the Ethics Committee of Tianjin Medical University of China on July 31, 2018 (approval No. IRB2018-088-01).
| S-EPMC7996011 | biostudies-literature
Project description:BackgroundBurr hole evacuation is a well-established treatment for symptomatic cases with chronic subdural hematoma (cSDH). Routinely postoperative catheter is left in the subdural space to drain the residual blood. Drainage obstruction is commonly seen, and it can be related to suboptimal treatment.MethodsTwo groups of patients submitted to cSDH surgery were evaluated in a retrospective non-randomized trial, one group that had conventional subdural drainage (CD group, n = 20) and another group that used an anti-thrombotic catheter (AT group, n = 14). We compared the obstruction rate, amount of drainage and complications. Statistical analyses were done using SPSS (v.28.0).ResultsFor AT and CD groups respectively (median ± IQR), the age was 68.23 ± 26.0 and 70.94 ± 21.5 (p > 0.05); preoperative hematoma width was 18.3 ± 11.0 mm and 20.7 ± 11.7 mm and midline shift was 13.0 ± 9.2 and 5.2 ± 8.0 mm (p = 0.49). Postoperative hematoma width was 12.7 ± 9.2 mm and 10.8 ± 9.0 mm (p < 0.001 intra-groups compared to preoperative) and MLS was 5.2 ± 8.0 mm and 1.5 ± 4.3 mm (p < 0.05 intra-groups). There were no complications related to the procedure including infection, bleed worsening and edema. No proximal obstruction was observed on the AT, but 8/20 (40%) presented proximal obstruction on the CD group (p = 0.006). Daily drainage rates and length of drainage were higher in AT compared to CD: 4.0 ± 1.25 days vs. 3.0 ± 1.0 days (p < 0.001) and 69.86 ± 106.54 vs. 35.00 ± 59.67 mL/day (p = 0.074). Symptomatic recurrence demanding surgery occurred in two patients of CD group (10%) and none in AT group (p = 0.230), after adjusting for MMA embolization, there was still no difference between groups (p = 0.121).ConclusionThe anti-thrombotic catheter for cSDH drainage presented significant less proximal obstruction than the conventional one and higher daily drainage rates. Both methods demonstrated to safe and effective for draining cSDH.
| S-EPMC10248548 | biostudies-literature