OBJECTIVE Chronic subdural hematoma (CSDH) is widely treated by drainage through a bur hole opening. However, whether and how preexisting comorbidities causing disturbance of consciousness affect patient outcomes remains unclear. METHODS The authors analyzed 188 consecutive patients with CSDH who were surgically treated at the Neurosurgery Institute of the Kyorin University School of Medicine between 2010 and 2012 and followed them for more than 90 days. The mean patient age was 77.0 years (range 33-101 years) and 56 were women. Patient outcomes including modified Rankin Scale (mRS) score, postoperative morbidity and mortality, and recurrence 90 days after initial surgery were analyzed according to preexisting comorbidities causing disturbance of consciousness. The comorbidities observed in 46 patients (24%) included dementia (30 patients), history of ischemic stroke (10 patients), psychiatric disorders (3 patients), and others (3 patients). RESULTS Background characteristics of patients with comorbidities showed older patient age (p < 0.001), lower preoperative Glasgow Coma Scale score (p < 0.001), and higher preoperative mRS score (p < 0.001). The mean mRS score 90 days after the neurosurgical procedure was 1.2 in all 188 patients, which was significantly higher in those with comorbidities (p < 0.001). By 1-way ANOVA with repeated measures, interaction existed between the presence of comorbidities and mRS score, and improvement of mRS score was observed in smaller proportions of patients with comorbidities (p = 0.002). By multivariate logistic regression analysis, the presence of comorbidities, patient age, reoperation for recurrence, and preoperative mRS score were significantly related to poor outcomes, defined as mRS score of 3 or more at 90 days after surgery. Postoperative morbidity (p < 0.01) and mortality (p < 0.01) were significantly higher in those with comorbidities, whereas the rate of recurrence of CSDH was not significantly different. CONCLUSIONS The preexistence of comorbidities causing disturbance of consciousness affected severity and outcomes 90 days after surgical treatment of CSDH, and comorbidities were also correlated with aging.
The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.
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