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Justin Schwarz, Joseph A. Carnevale, Jacob L. Goldberg, Alexander D. Ramos, Thomas W. Link, and Jared Knopman

OBJECTIVE

Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone.

METHODS

Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging.

RESULTS

There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention.

CONCLUSIONS

Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

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Joseph A. Carnevale, David J. Segar, Andrew Y. Powers, Meghal Shah, Cody Doberstein, Benjamin Drapcho, John F. Morrison, John R. Williams, Scott Collins, Kristina Monteiro, and Wael F. Asaad

OBJECTIVE

Traumatic brain injury (TBI) remains a significant cause of neurological morbidity and mortality. Each year, more than 1.7 million patients present to the emergency department with TBI. The goal of this study was to evaluate the prognosis of traumatic cerebral intraparenchymal hemorrhage (tIPH), to develop subclassifications of these injuries that relate to prognosis, and to provide a more comprehensive assessment of hemorrhagic progression contusion (HPC) by analyzing the rate at which tIPH “blossom” (i.e., expansion), depending on a variety of intrinsic and modifiable factors.

METHODS

In this retrospective study, 726 patients (age range 0–100 years) were admitted to a level 1 trauma center with tIPH during an 8-year period (2005–2013). Of these patients, 491 underwent both admission and follow-up head CT (HCT) within 72 hours. The change in tIPH volume over time, the expansion rate, was recorded for all 491 patients. Effects of prehospital and in-hospital variables were examined using ordinal response logistic regression analyses. These variables were further examined using multivariate linear regression analysis to accurately predict the extent to which a hemorrhage will progress.

RESULTS

Of the 491 (67.6%) patients who underwent both admission and follow-up HCT, 368 (74.9%) patients experienced HPC. These hemorrhages expanded on average by 61.6% (4.76 ml) with an average expansion rate of 0.71 ml per hour. On univariate analysis, certain patient characteristics were significantly (p < 0.05) related to HPC, including age (> 60 years), admission Glasgow Coma Scale score, blood alcohol level, international normalized ratio, absolute platelet count, transfusion of platelets, concomitant anticoagulation and antiplatelet medication, the initial tIPH volume on admission HCT, and ventriculostomy. Increased expansion rate was significantly associated with patient disposition to hospice or death (p < 0.001). To determine which factors most accurately predict overall patient disposition, an ordinal-response logistic regression identified systolic blood pressure, Injury Severity Score, admission Glasgow Coma Scale score, follow-up scan volume, transfusion of platelets, and ventriculostomy as predictors of patient discharge disposition following tIPH. A multivariate logistic regression identified several prehospital and in-hospital variables (age, Injury Severity Score, blood alcohol level, initial scan volume, concomitant epidural hematoma, presence of subarachnoid hemorrhage, transfusion of platelets, and ventriculostomy) that predicted the volumetric expansion of tIPH. Among these variables, the admission tIPH volume by HCT proved to be the factor most predictive of HPC.

CONCLUSIONS

Several factors contribute to the rate at which traumatic cerebral contusions blossom in the acute posttraumatic period. Identifying the intrinsic and modifiable aspects of cerebral contusions can help predict the rate of expansion and highlight potential therapeutic interventions to improve TBI-associated morbidity and mortality.