Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
View/Download PDF

Translate this page into:

Commentary
10 (
1
); 118-119
doi:
10.4103/jnrp.jnrp_316_18

Commentary

Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
Address for correspondence: Dr. Matteo Zoli, Department of Biomedical and Neuromotor Sciences, University of Bologna, and Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. E-mail: matteo.zoli4@unibo.it

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Although the incidence of chronic subdural hematoma (CSDH) is assessed about 1–5.3 case per 100,000 individuals yearly, this is a real emerging disease in consideration to the increasing average age of the general population.[1] For such reasons, this disease may have a deep effect on the socio-sanitary systems of many countries, leading to a progressive increase of healthcare costs and patient hospitalization.[1] Moreover, CSDH has a relevant impact, also, for patients: indeed, in fragile elderly ones, often with multiple comorbidities, the reduction of autonomous activities in daily life may lead to a relevant decrease of their quality of life, and according to some studies, also, to a reduction in the expected survival time.[2] Furthermore, it has been suggested to consider CSDH as a form of reversible dementia, with a progressive decline in mental and physical performance, sometimes associated to clear focal neurological deficits, which can be reversed after treatment, at least to some degrees.[1]

Based on these considerations, it is not surprising that this condition is central in the scientifical debate, as demonstrated by a large number of publications in the field. In 2017, 191 papers were reported in the medical literature on this topic, and in the first 9 months of 2018, about 135 have been already accepted for publication. Most of them are focused on the more appropriate surgical treatment for this condition. Indeed, despite its high incidence, no consensus has been reached on the most effective surgical technique, even after randomized controlled trials and wide meta-analyses.[34] Considering that the selection of the most appropriate surgical management is a prominent key of success, the relevance of this discussion is evident.[4] In their paper, Martin et al. report their technique, consisting in the insertion of two drainages through a burr hole, to achieve a better irrigation of the hematoma and a reduction of the risk of postoperative pneumocephalus.[5] The paper is interesting because, as stated by the authors, they combine some known technical principles of CSDH surgery, such as postoperative drainage, saline solution irrigation, with some innovative nuances to reduce the presence of postoperative intracranial air, which is known to be associated to a higher risk of recurrence of the hematoma.[5]

Although we strongly believe that the efforts by the authors are commendable, we, also, consider that it is time to change the paradigm in the scientific literature on this field.[6] Indeed, for some aspects, the final prognosis of patients with CSDH is only partially dependent on the technical issue, it is, also, due to the patient's clinical condition, comorbidities, and medical therapies.[78] To some extent, we face the paradoxical scenario that one of the less technical demanding neurosurgical maneuver, usually quick, with low complication, and even not always requiring general anesthesia, could lead to scarcely acceptable results. Indeed, if we accept that CSDH manifests as a reversible form of dementia, the aim of any treatment should be the restoring of the patients’ previous quality of life, independence in daily activities, and general performance. However, a common observation in routine practice is that the functional sequelae are often severe, also in cases with an excellent surgical outcome of the hematoma. In fact, in a not negligible rate of cases, the final clinical status is far from the desirable, with a substantial regression of quality of life.[678] We agree with many studies that the comorbidities of patients, their initial clinical conditions, and the radiological features of the hematoma are relevant prognostic factors, which should be considered to predict the final patient's outcome.[678] Revising our surgical experience on 216 CSDH cases operated between 2013 and 2015, we found that patients older than 81 (hazard ratio [HR]: 6.16 e P < 0.0001), with cardiological comorbidities (HR: 1.88 e P = 0.04.), or chronic pneumatics (HR: 2.43, P = 0.003), or preoperative dementia (HR: 2.04, P = 0.03) or worse neurological condition at surgery, evaluated basing on the Glasgow Coma Scale (HR: 2.04, P = 0.03), presented a shorter survival time at a multivariate statistical analysis despite the resolution of CSDH on postoperative scans.

Considering the prominent costs of CSDH not only for the health systems but also for patients, caregivers, their families, and for the society, we consider that the main issue in this pathology is the discrepancy between the easy and quick technical aspects of this surgery and the poor prognosis of some of these cases. Therefore, we hope that future studies will enlighten the role of each of prognostic factor, to help clinicians in the more difficult issue in CSDH: the selection of the better surgical indications as possible.

REFERENCES

  1. , , , , , . Chronic subdural hematoma: A Historical and clinical perspective. World Neurosurg. 2017;108:948-53.
    [Google Scholar]
  2. , , , , . Chronic subdural hematoma in the elderly: Not a benign disease. J Neurosurg. 2011;114:72-6.
    [Google Scholar]
  3. , , , . Chronic subdural hematoma: A systematic review and meta-analysis of surgical procedures. J Neurosurg. 2014;121:665-73.
    [Google Scholar]
  4. , , , , , . Surgical management of chronic subdural hematomas: In need of better evidence. Acta Neurochir (Wien). 2013;155:183-4.
    [Google Scholar]
  5. , , , , . Burr-hole evacuation of chronic subdural hematoma: Biophysically and evidence based technique improvement. J Neurosci Rural Pract. 2018;10:113-8.
    [Google Scholar]
  6. , , , , , , . Chronic subdural hematoma: Toward a new management paradigm for an increasingly complex population. J Neurotrauma. 2018;35:1882-5.
    [Google Scholar]
  7. , , , , , . Prognostic scoring for chronic subdural hematoma: Is decision making easier? World Neurosurg. 2018;116:481.
    [Google Scholar]
  8. , , , , , , . MYH9-related thrombocytopenia and intracranial bleedings: A complex clinical/surgical management and review of the literature. Br J Haematol. 2015;170:729-31.
    [Google Scholar]

    Fulltext Views
    312

    PDF downloads
    344
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections