RESUMEN

BACKGROUND: Chronic subdural hematoma (cSDH) in children is associated with several etiologies, one of which is nonaccidental trauma (NAT). Performed alone or as an adjunct to surgical intervention, middle meningeal artery (MMA) embolization may be effective in resolving and preventing the recurrence of cSDH in adult patients. However, MMA embolization for pediatric cSDH has not been adequately evaluated, and there exists no consensus on the appropriate selection of pediatric patients for this minimally invasive procedure. Appreciating the variable underlying pathophysiology of pediatric cSDH will enable the development of guidelines for patient selection. OBSERVATIONS: A 14-month-old female patient presented with depressed consciousness, seizure-like activity, and apneic episodes. She was diagnosed with bilateral subacute on chronic SDH associated with NAT, and imaging revealed diffuse brain atrophy. Despite undergoing burr hole drainage, she developed refractory cSDH and was treated with bilateral MMA embolization. At her 10-month follow-up, magnetic resonance imaging revealed a decrease in the size of the subdural collections, and she was tolerating feeds, at her neurological baseline, and seizure-free. LESSONS: Infants and young children with symptomatic cSDH secondary to NAT, whose tissue dynamics are reminiscent of cSDH in elderly patients with diffuse brain atrophy, may derive the most benefit from MMA embolization.

RESUMEN

BACKGROUND: Chronic subdural hematoma (CSDH) is sometimes refractory, and this is troublesome for neurosurgeons. Although many studies have reported risk factors or treatments in efforts to prevent recurrence, those have focused on single recurrence, and few cumulative data are available to analyze refractory CSDH. METHODS: We defined refractory CSDH as ≥2 recurrences, then analyzed and compared clinical factors between patients with single recurrence and those with refractory CSDH in a cohort study, to clarify whether patients with refractory CSDH experience different or more risk factors than patients with single recurrence, and whether burr-hole irrigation with closed-system drainage reduces refractory CSDH. RESULTS: Seventy-five patients had at least 1 recurrence, with single recurrence in 62 patients and ≥2 recurrences in 13 patients. In comparing clinical characteristics, patients with refractory CSDH were significantly younger (P = 0.04) and showed shorter interval to first recurrence (P < 0.001). Organized CSDH was also significantly associated with refractory CSDH (P = 0.02). Multivariate logistic regression analysis identified first recurrence interval <1 month (odds ratio, 6.66, P < 0.001) and age <71 years (odds ratio, 4.16, P < 0.001) as independent risk factors for refractory CSDH. On the other hand, burr-hole irrigation with closed-system drainage did not reduce refractory CSDH. CONCLUSIONS: When patients with risk factors for refractory CSDH experience recurrence, alternative surgical procedures may be considered as the second surgery, because burr-hole irrigation with closed-system drainage did not reduce refractory CSDH in our study.

Asunto(s)

Procedimientos Endovasculares/métodos , Hematoma Subdural Crónico/cirugía , Anciano , Craneotomía/métodos , Drenaje/métodos , Femenino , Humanos , Masculino , Medicina Kampo , Neuroimagen , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos X

RESUMEN

Middle meningeal artery (MMA) embolization has been performed to treat refractory chronic subdural hematoma (CSDH) with good reported outcomes. We have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization.