Background: Chronic Subdural Hematoma (CSDH) is a common condition in the elderly population. Recurrence rates after surgical evacuation range from 5 to 30%. Factors predicting recurrence remain debated and unclear.Objective: To identify factors associated with increased risk of recurrence.Methods: Cases of CSDHs that underwent surgical treatment between 2005 and 2018 in the Neurosurgery Units of two major Italian hospitals were reviewed. Data extracted from a prospectively maintained database included demographics, laterality, antithrombotic therapy, history of trauma, corticosteroid therapy, preoperative and postoperative symptoms, type of surgical intervention, use of surgical drain, and clinical outcomes.Results: A total of 1313 patients was analyzed. The overall recurrence rate was 10.1%. The risk of recurrence was not significantly different between patients with unilateral or bilateral CSDH (10.4 vs. 8.8%, p = 0.39). The risk of recurrence was higher in patients that underwent surgical procedure without postoperative drainage (16.1 vs. 5.4%, p < 0.01). No relationship was found between recurrence rates and therapy with antithrombotic drugs (p = 0.97). The risk of recurrence was increasingly higher considering craniostomy, craniectomy, and craniotomy (9.3, 11.3, and 18.9%, respectively, p = 0.013). Lower recurrence rates following Dexamethasone therapy were recorded (p = 0.013).Conclusion: No association was found between the risk of recurrence of CSDH after surgical evacuation and age, use of antithrombotic medication, or laterality. Burr-hole craniostomy was found to be associated with lower recurrence rates, when compared to other surgical procedures. Placement of surgical drain and Dexamethasone therapy were significantly associated with reduced risk of recurrence of CSDHs.

Background Spinal arteriovenous fistulas (AVFs) are uncommon vascular malformations of spinal dural and epidural vessels. Actually digital subtraction angiography (DSA) is the gold standard for diagnosis and follow-up. The aim of this study is to demonstrate the validity of the multiphasic magnetic resonance angiography (MRA) to identify recurrent/residual AVFs or their correct surgical and/or endovascular closure. Methods A retrospective cases series with perimedullary venous plexus congestion due to spinal dural or epidural AVF was performed at our center from April 2014 to September 2019. After 1 month from treatment, the patients were subjected to time-resolved MRA and DSA to demonstrate recurrence or correct closure of AVFs. Results We collected a series of 26 matched time-resolved MRA and DSA in 20 patients who underwent an endovascular and/or surgical procedure. In our series, we reported five cases of recurrence. Time-resolved MRA detected six cases of recurrence, with 100% sensitivity and 95% specificity (p < 0.001). We used DSA as the standard reference. Conclusion Time-resolved MRA is a valid tool in posttreatment follow-up to detect recurrent or residual AVFs. It has high sensitivity and specificity and may replace DSA.

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IntroductionSpinal dural arteriovenous fistula consist of an heterogenous group of vascular malformation often causing severe neurological deficit due to progressive myelopathy. This type of malformation could be associated with subarachnoid or subdural hemorrhage inside the spinal canal. In the English literature surgical treatment is regarded as the best option if compared to endovascular procedure, being the latter associated with an increased risk of relapse despite its less invasiveness.MethodsIn this study a retrospective analysis of 30 patients with spinal dural and epidural fistula associated with perimedullary venous congestion was undertaken. The radiological and clinical presentation of each patient is analyzed, and the grade of myelopathy is classified through the mJOA score.ResultsA total number of 31 out of 41 collected procedures (22 surgery vs. 19 endovascular) were dural fistulas while the remaining 10 were classified as epidural. A 46% recurrence rate for endovascular treatment against 0% for surgical (p-value 0.004) was described for dural fistulas, while in the epidural fistula group the rate of recurrence was 80% and 20% respectively for endovascular and surgery treatment (p-value 0.6).DiscussionAccording to the results, surgical treatment could be considered as first-line treatment for spinal dural arteriovenous fistulas. Endovascular embolization can be proposed in selected cases, as a less invasive technique, for elderly patients or with important comorbidities. In spinal epidural arteriovenous fistulas, in view of the greater invasiveness of the surgical treatment and the non-significant difference in terms of recurrence risk between the two techniques, endovascular treatment could be proposed as a first choice treatment; in the event of a recurrence, a surgical intervention will instead be proposed in a short time.

Background: Cerebral cavernous malformations (CCMs) are a major type of cerebrovascular lesions of proven genetic origin that occur in either sporadic (sCCM) or familial (fCCM) forms, the latter being inherited as an autosomal dominant condition linked to loss-of-function mutations in three known CCM genes. In contrast to fCCMs, sCCMs are rarely linked to mutations in CCM genes and are instead commonly and peculiarly associated with developmental venous anomalies (DVAs), suggesting distinct origins and common pathogenic mechanisms. Case report: A hemorrhagic sCCM in the right frontal lobe of the brain was surgically excised from a symptomatic 3 year old patient, preserving intact and pervious the associated DVA. MRI follow-up examination performed periodically up to 15 years after neurosurgery intervention demonstrated complete removal of the CCM lesion and no residual or relapse signs. However, 18 years after surgery, the patient experienced acute episodes of paresthesia due to a distant recurrence of a new hemorrhagic CCM lesion located within the same area as the previous one. A new surgical intervention was, therefore, necessary, which was again limited to the CCM without affecting the pre-existing DVA. Subsequent follow-up examination by contrast-enhanced MRI evidenced a persistent pattern of signal-intensity abnormalities in the bed of the DVA, including hyperintense gliotic areas, suggesting chronic inflammatory conditions. Conclusions: This case report highlights the possibility of long-term distant recurrence of hemorrhagic sCCMs associated with a DVA, suggesting that such recurrence is secondary to focal sterile inflammatory conditions generated by the DVA.