Double-crescent sign as a predictor of chronic subdural hematoma recurrence following burr-hole surgery

Restricted access

OBJECTIVE

Subdural hygroma has been reported as a causative factor in the development of a chronic subdural hematoma (CSDH) following a head trauma and/or neurosurgical procedure. In some CSDH cases, the presence of a 2-layered space delineated by the same or similar density of CSF surrounded by a superficial, residual hematoma is seen on CT imaging after evacuation of the hematoma. The aims of the present study were to test the hypothesis that the double-crescent sign (DCS), a unique imaging finding described here, is associated with the postoperative recurrence of CSDH, and to investigate other factors that are related to CSDH recurrence.

METHODS

The authors retrospectively analyzed data from 278 consecutive patients who underwent single burr-hole surgery for CSDH between April 2012 and March 2017. The DCS was defined as a postoperative CT finding, characterized by the following 2 layers: a superficial layer demonstrating residual hematoma after evacuation of the CSDH, and a deep layer between the brain’s surface and the residual hematoma, depicted as a low-density space. Correlation of the recurrence of CSDH with the DCS was evaluated by multivariate logistic regression modeling. The authors also investigated other classic predictive factors including age, sex, past history of head injury, hematoma laterality, anticoagulant and antiplatelet therapy administration, preoperative hematoma volume, postoperative residual hematoma volume, and postoperative brain reexpansion rate.

RESULTS

A total of 277 patients (320 hemispheres) were reviewed. Fifty (18.1%) of the 277 patients experienced recurrence of CSDH within 3 months of surgery. CSDH recurred within 3 months of surgery in 32 of the 104 hemispheres with a positive DCS. Multivariate logistic analyses revealed that the presence of the DCS (OR 3.36, 95% CI 1.72–6.57, p < 0.001), large postoperative residual hematoma volume (OR 2.88, 95% CI 1.24–6.71, p = 0.014), anticoagulant therapy (OR 3.03, 95% CI 1.02–9.01, p = 0.046), and bilateral hematoma (OR 3.57, 95% CI 1.79–7.13, p < 0.001) were significant, independent predictors of CSDH recurrence.

CONCLUSIONS

In this study, the authors report that detection of the DCS within 7 days of surgery is an independent predictive factor for CSDH recurrence. They therefore advocate that clinicians should carefully monitor patients for postoperative DCS and subsequent CSDH recurrence.

ABBREVIATIONS APTT = activated partial thromboplastin time; ASDH = acute subdural hematoma; CSDH = chronic subdural hematoma; DBC = dural border cell; DCS = double-crescent sign; HU = Hounsfield unit; JCS = Japan Coma Scale; POD = postoperative day; PRH = postoperative residual hematoma; PT-INR = prothrombin time–international normalized ratio; ROC-AUC = receiver operating characteristic–area under the curve.
Article Information

Contributor Notes

Correspondence Hiroshi Abe: Fukuoka University, Fukuoka, Japan. neuroabe1972@gmail.com.INCLUDE WHEN CITING Published online January 4, 2019; DOI: 10.3171/2018.8.JNS18805.Disclosures Dr. Arima has received lecture fees from Bayer, Daiichi-Sankyo, and Takeda. Dr. Morishita has received honoraria from Boston Scientific and Medtronic as a consultant within the past 12 months.
Headings
References
  • 1

    Almenawer SAFarrokhyar FHong CAlhazzani WManoranjan BYarascavitch B: Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg 259:4494572014

    • Search Google Scholar
    • Export Citation
  • 2

    Bartek J JrSjåvik KKristiansson HStåhl FFornebo IFörander P: Predictors of recurrence and complications after chronic subdural hematoma surgery: a population-based study. World Neurosurg 106:6096142017

    • Search Google Scholar
    • Export Citation
  • 3

    Chari AHocking KCEdlmann ETurner CSantarius THutchinson PJ: Core outcomes and common data elements in chronic subdural hematoma: a systematic review of the literature focusing on baseline and peri-operative care data elements. J Neurotrauma 33:156915752016

    • Search Google Scholar
    • Export Citation
  • 4

    Dierckx RABruyland MNuyens ZStadnik TSolheid CEbinger G: Non-traumatic subdural hygroma. Acta Neurol Belg 89:3523571989

  • 5

    Haines DEHarkey HLal-Mefty O: The “subdural” space: a new look at an outdated concept. Neurosurgery 32:1111201993

  • 6

    Ivamoto HSLemos HP JrAtallah AN: Surgical treatments for chronic subdural hematomas: a comprehensive systematic review. World Neurosurg 86:3994182016

    • Search Google Scholar
    • Export Citation
  • 7

    Jack AO’Kelly CMcDougall CFindlay JM: Predicting recurrence after chronic subdural haematoma drainage. Can J Neurol Sci 42:34392015

    • Search Google Scholar
    • Export Citation
  • 8

    Kudo HKuwamura KIzawa ISawa HTamaki N: Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect. Neurol Med Chir (Tokyo) 32:2072091992

    • Search Google Scholar
    • Export Citation
  • 9

    Lee KS: The pathogenesis and clinical significance of traumatic subdural hygroma. Brain Inj 12:5956031998

  • 10

    Lee KSBae WKBae HGYun IG: The fate of traumatic subdural hygroma in serial computed tomographic scans. J Korean Med Sci 15:5605682000

    • Search Google Scholar
    • Export Citation
  • 11

    Leroy HAAboukaïs RReyns NBourgeois PLabreuche JDuhamel A: Predictors of functional outcomes and recurrence of chronic subdural hematomas. J Clin Neurosci 22:189519002015

    • Search Google Scholar
    • Export Citation
  • 12

    Liu WBakker NAGroen RJ: Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121:6656732014

    • Search Google Scholar
    • Export Citation
  • 13

    Mori KMaeda M: Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:3713812001

    • Search Google Scholar
    • Export Citation
  • 14

    Motiei-Langroudi RStippler MShi SAdeeb NGupta RGriessenauer CJ: Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation. J Neurosurg 129:114311502018

    • Search Google Scholar
    • Export Citation
  • 15

    Nabeshima SReese TSLandis DMBrightman MW: Junctions in the meninges and marginal glia. J Comp Neurol 164:1271691975

  • 16

    Nakaguchi HTanishima TYoshimasu N: Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence. J Neurosurg 95:2562622001

    • Search Google Scholar
    • Export Citation
  • 17

    Nakaguchi HTanishima TYoshimasu N: Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage. J Neurosurg 93:7917952000

    • Search Google Scholar
    • Export Citation
  • 18

    Nayil KRamzan ASajad AZahoor SWani ANizami F: Subdural hematomas: an analysis of 1181 Kashmiri patients. World Neurosurg 77:1031102012

    • Search Google Scholar
    • Export Citation
  • 19

    Nomura SKashiwagi SFujisawa HIto HNakamura K: Characterization of local hyperfibrinolysis in chronic subdural hematomas by SDS-PAGE and immunoblot. J Neurosurg 81:9109131994

    • Search Google Scholar
    • Export Citation
  • 20

    Park JCho JHGoh DHKang DHShin IHHamm IS: Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors. J Neurosurg 124:3103172016

    • Search Google Scholar
    • Export Citation
  • 21

    Park SHLee SHPark JHwang JHHwang SKHamm IS: Chronic subdural hematoma preceded by traumatic subdural hygroma. J Clin Neurosci 15:8688722008

    • Search Google Scholar
    • Export Citation
  • 22

    Schwarz FLoos FDünisch PSakr YSafatli DAKalff R: Risk factors for reoperation after initial burr hole trephination in chronic subdural hematomas. Clin Neurol Neurosurg 138:66712015

    • Search Google Scholar
    • Export Citation
  • 23

    Stanisic MPripp AH: A reliable grading system for prediction of chronic subdural hematoma recurrence requiring reoperation after initial burr-hole surgery. Neurosurgery 81:7527602017

    • Search Google Scholar
    • Export Citation
  • 24

    Stavrinou PKatsigiannis SLee JHHamisch CKrischek BMpotsaris A: Risk factors for chronic subdural hematoma recurrence identified using quantitative computed tomography analysis of hematoma volume and density. World Neurosurg 99:4654702017

    • Search Google Scholar
    • Export Citation
  • 25

    Sucu HKGokmen MGelal F: The value of XYZ/2 technique compared with computer-assisted volumetric analysis to estimate the volume of chronic subdural hematoma. Stroke 36:99810002005

    • Search Google Scholar
    • Export Citation
  • 26

    Torihashi KSadamasa NYoshida KNarumi OChin MYamagata S: Independent predictors for recurrence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery 63:112511292008

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 90 90 90
Full Text Views 45 45 45
PDF Downloads 72 72 72
EPUB Downloads 0 0 0
PubMed
Google Scholar