Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation

Abstract

OBJECTIVE Chronic subdural hematoma (CSDH) is commonly encountered in neurosurgical practice. However, surgical evacuation remains complicated by a high rate of reoperation. The optimal surgical approach to reduce the reoperation rate has not been determined. In the current study, the authors evaluated the prognostic value of clinical and radiographic factors to predict reoperation in the context of CSDH. METHODS A retrospective review of 325 CSDH patients admitted to an academic medical center in the United States, between 2006 and 2016, was performed. Clinical and radiographic factors predictive of the need for CSDH reoperation were identified on univariable and multivariable analyses. RESULTS Univariable analysis showed that warfarin use, clopidogrel use, mixed hypo- and isointensity on T1-weighted MRI, greater preoperative midline shift, larger hematoma/fluid residual on first postoperative day CT, lesser decrease in hematoma size after surgery, use of monitored anesthesia care (MAC), and lack of intraoperative irrigation correlated with a significantly higher rate of reoperation. Multivariable analysis, however, showed that only the presence of loculation, clopidogrel or warfarin use, and percent of hematoma change after surgery significantly predicted the need for reoperation. Our results showed that 0% (no reduction), 50%, and 100% hematoma maximum thickness change (complete resolution of hematoma after surgery) were associated with a 41%, 6%, and < 1% rate of reoperation, respectively. The use of drains, either large diameter or small caliber, did not have any effect on the likelihood of reoperation. CONCLUSIONS Among many factors, clopidogrel or warfarin use, hematoma loculation on preoperative CT, and the amount of hematoma evacuation on the first postoperative CT were the strongest predictors of reoperation.

Predictors of acute intracranial hemorrhage and recurrence of chronic subdural hematoma following burr hole drainage

“…CSDH is one of the most commonly treated neurosurgical disorders and BHD is a universal surgical treatment [11,18,27]. The rate of CSDH recurrence following BHD is 4-38% and the complications rate is 0-38% [6-12, 24, 26].…”

“…BHD is the most widely used technique, and has a satisfactory outcome, but has a CSDH recurrence rate of 4-38% [6][7][8][9][10][11][12]. Several studies have revealed that predictors of CSDH recurrence following surgical evacuation include age, sex, antiplatelet or anticoagulation therapy, Glasgow Coma Scale (GCS), diabetes mellitus, hypertension, bilateral hematoma, preoperative hematoma size, midline shift, hematoma density, intraoperative irrigation, type of surgery and postoperative air collection, however, these results are inconsistent [7,[13][14][15][16][17][18][19]. The more controversial risk factors include surgery type and intraoperative irrigation [9,10,[20][21][22].…”

Endoscopic Management of Chronic Subdural Hematoma

“…Although we used endoscopic surgery in all types of CSDH, patients with a higher risk of recurrence could be good candidates for such procedures. Patients on antiplatelet therapy, 51,52 organized hematoma, 53 solid clot, [53][54][55] large size hematomas, 56 CSDH with thick membrane, 57,58 septate hematomas, 52,59,60 a lesser percentage of hematoma drainage, 52,55 more postoperative air in the hematoma cavity, 61,62 and recurrent CSDH 21 are at high risk of recurrences. Such patients could benefit more by endoscopic surgery.…”

Letter to the Editor. Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies

“…1,5 The best evidence, published in the systematic reviews of Malcolm et al and van de Vijfeijken et al, shows a higher failure risk in autologous bone than allografts, which brings to light synthetic implants and favors the decision to use them. 6,7 In this analysis, the significantly higher rates of reoperation in patients with autologous implants are primarily due to bone resorption. The factors that result in clinically relevant bone resorption remain unclear.…”