Key-words:
Chronic subdural hematoma - burr hole trephination - meningeal artery embolization
Introduction
Chronic subdural hematoma is common among the elderly. Physical status is an important
factor when considering patient management. Burr hole trephination is minimally invasive
and is used worldwide for surgical management of this condition. However, surgical
methods must be selected after careful consideration of mortality, morbidity, and
recurrence rates.
We present a case of chronic subdural hematoma, wherein burr hole trephination was
repeatedly performed because of hematoma recurrence; the patient finally underwent
decompressive craniectomy with middle meningeal artery embolization.
Case Report
A 65-year-old woman with pulmonary thromboembolism and acute kidney injury (AKI) in
chronic kidney disease (CKD) was admitted to the hospital with dyspnea lasting for
1 week. Sulodexide (250 LSU) was administered orally for 4 days, and clexane (60 mg)
injections were administered for 3 days, starting on the 2nd day of admission. The
patient's initial mental status was alert; however, on the 4th day, she developed
stupor. A nonenhanced brain computed tomography (CT) revealed a left chronic subdural
hematoma [[Figure 1]].
Figure 1: Initial brain nonenhanced computed tomography images of the patient. Brain computed
tomography showed chronic subdural hematoma with minimal amount acute subdural hemorrhage
and midline shift
The patient was categorized as having an American Society of Anesthesiologists (ASA)
physical status classification of IV (defined as “A patient with severe systemic disease
that is a constant threat to life”). Because of this and the patient's history of
having received clexane injections within the last 12 h, emergency burr hole trephination
was performed. After the operation, the patient's neurologic status recovered fully.
Twelve days after surgery, the patient was found wandering in a delirious state. A
follow-up brain CT [[Figure 2]] revealed recurrence of the left subdural hematoma with a small amount of acute
hemorrhage. Burr hole trephination was performed again. The subdural drainage catheter
was removed the day after the operation. However, the next day, the patient's motor
grade decreased with increased sleeping tendency. Follow-up brain CT showed recurrence
of the hemorrhage [[Figure 3]]. A third burr hole trephination and significant volume of saline irrigation were
performed. The next day, the patient's subdural drain was removed. Four days after
removal of the drain, the patients' general condition was found to have worsened again.
Exaggerated lethargy and aphasia were also noted. Follow-up brain CT showed mixed
subdural hemorrhage and increased fluid collection at the site of the preexisting
subdural hemorrhage [[Figure 4]]. The patient then underwent decompressive craniectomy, which is associated with
a relatively low hematoma recurrence rate. On opening the dura, a minor subdural hemorrhage,
moderate degree of brain swelling, and diffuse oozing without focal bleeding were
noted. Coagulation using bipolar coagulator was consequently performed. After confirming
bleeding cessation, duroplasty was performed using an artificial dura (Surgisis Biodesign
Dural Graft, COOK Medical 7 cm × 10 cm), and the operation was complete [[Figure 5]].
Figure 2: Follow-up brain computed tomography image 12 days after the operation. Brain computed
tomography showed recurrence of left subdural hematoma
Figure 3: Follow-up brain computed tomography image showed recurrence of left subdural hematoma
with midline shift
Figure 4: Follow-up brain computed tomography image showed subacute subdural hematoma with
midline shift
Figure 5: (a) Clinical photo of the patient during decompressive craniectomy with duroplasty.
(b) Follow.up brain computed tomography image after decompressive craniectomy showing
improvement of midline shift
Middle meningeal artery embolization, with continuous renal replacement therapy for
the existing CKD, was additionally performed for the recurrent subdural hemorrhage.
Hemorrhagic spread to additional subdural areas was not noted, although the left middle
meningeal artery was unusually thickened [[Figure 6]]a; complete embolization with histoacryl and lipiodol was successfully performed
[[Figure 6]]b.
Figure 6: Angiography showing thickened left middle meningeal artery. (a) Angiography of the
left middle meningeal artery. (b) Embolization of the left middle meningeal artery
was performed completely
Three days after embolization, the patient demonstrated increased lethargy once again.
A follow-up brain CT revealed epidural hemorrhage at the site of the decompressive
craniectomy. Brain compression by the hemorrhage was also noted [[Figure 7]]. Re-operation for cranioplasty with hematoma removal was done. No hemorrhagic focus
was confirmed and the hemorrhage noticed on the CT image was bulging of styptic agent
and artificial dura with the absorption of the old hematoma. Saline irrigation and
bleeding control were achieved via bipolar coagulation, followed by cranioplasty.
After the operation, the patient returned to an alert state, maintained ambulation,
and was discharged after a follow-up brain CT scan confirming resolution of the hemorrhage
[[Figure 8]].
Figure 7: Follow-up brain computed tomography image of the patient showing left epidural hematoma
compressing the brain
Figure 8: Brain computed tomography image before patient discharge. No hemorrhage and midline
shift were noticed
Discussion
The three main operative methods for chronic subdural hematoma management are twist
drill trephination, burr hole trephination, and craniotomy. Each surgical procedure
is associated with distinct morbidity, mortality, and recurrence rates, which vary
across studies, making it impossible to determine which is superior.[[1]],[[2]] Therefore, we chose an operative method based on the patient's clinical status
and general condition. Burr hole trephination is a relatively short procedure and
is associated with lower morbidity and mortality rates compared to craniotomy, which
requires a longer operating time, creation of a larger bone flap, and involves more
bleeding.[[1]],[[2]],[[3]] However, hemorrhage recurrence rates are higher after burr hole trephination than
after craniotomy.
The ASA classification of physical status is used worldwide to assess for the risk
of general anesthesia, although studies in this regard are still lacking in the field
of neurosurgery.[[4]],[[5]],[[6]] The patient discussed here was initially categorized as ASA class 4, indicating
a high risk for general anesthesia. It was one of the main reasons that burr hole
trephination was determined to be more surgically acceptable than craniotomy at first.
It is highly probable that the patient's preexisting CKD caused defective coagulation,
resulting in diffuse oozing without focal bleeding.[[7]] Patients with kidney disease are more likely to exhibit coagulopathies, which may
be present in the absence of other abnormal laboratory results.[[7]] The patient in this case presented with AKI in CKD at admission, which may have
affected the recurrent hemorrhage.
Middle meningeal artery embolization, an additional, alternative method for treating
recurrent subdural hemorrhage, was also used in the case outlined here. We were unable
to confirm a causal relationship between the thickening of the left meningeal artery
and the recurrent subdural hemorrhage. It is also possible that meningeal artery thickening
may have affected this patient's clinical progress, given the therapeutic effects
of embolization. Additional studies on the effectiveness of embolization may support
this conclusion.[[8]],[[9]]
Conclusion
This patient ultimately underwent three burr hole trephination surgeries before a
decompressive craniectomy was finally performed. Despite poor patient physical status,
minimally invasive operation may not always be the best option. In addition, in patients
with a pre-existing diminished physical status, especially kidney disease, coagulopathies
may occur, and special attention should be paid to possible additional complications,
such as epidural hemorrhage.
Determining the definite effect of embolization when a comparable control is not available
is not possible. However, as the hemorrhage, in this case, did not expand the following
cranioplasty, embolization for recurrent subdural hemorrhage may be an effective treatment.
In cases with high bleeding risk, embolization should be carefully considered.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
