Chronic Subdural Hematoma:Evolution through time

The main focus of this thesis was to evaluate the effect of corticosteroids in CSDH treatment. The current evidence suggests that corticosteroids should not be used as stand-alone treatment. Furthermore, there is no high-level evidence to use dexamethasone as additional treatment in the standard care of CSDH patients. Burr hole craniostomy is the preferred treatment option in patients with neurological deficits. With an (inter)national collaborative approach and a large-scale prospective registry we will be able to develop more insight and share ideas on new high-quality trials.<br/

Associations among unit leadership and unit climates for implementation in acute care: a cross-sectional study

Abstract Background Nurse managers have a pivotal role in fostering unit climates supportive of implementing evidence-based practices (EBPs) in care delivery. EBP leadership behaviors and competencies of nurse managers and their impact on practice climates are widely overlooked in implementation science. The purpose of this study was to examine the contributions of nurse manager EBP leadership behaviors and nurse manager EBP competencies in explaining unit climates for EBP implementation in adult medical-surgical units. Methods A multi-site, multi-unit cross-sectional research design was used to recruit the sample of 24 nurse managers and 553 randomly selected staff nurses from 24 adult medical-surgical units from 7 acute care hospitals in the Northeast and Midwestern USA. Staff nurse perceptions of nurse manager EBP leadership behaviors and unit climates for EBP implementation were measured using the Implementation Leadership Scale and Implementation Climate Scale, respectively. EBP competencies of nurse managers were measured using the Nurse Manager EBP Competency Scale. Participants were emailed a link to an electronic questionnaire and asked to respond within 1 month. The contributions of nurse manager EBP leadership behaviors and competencies in explaining unit climates for EBP implementation were estimated using mixed-effects models controlling for nurse education and years of experience on current unit and accounting for the variability across hospitals and units. Significance level was set at α < .05. Results Two hundred sixty-four staff nurses and 22 nurse managers were included in the final sample, representing 22 units in 7 hospitals. Nurse manager EBP leadership behaviors (p < .001) and EBP competency (p = .008) explained 52.4% of marginal variance in unit climate for EBP implementation. Leadership behaviors uniquely explained 45.2% variance. The variance accounted for by the random intercepts for hospitals and units (p < .001) and years of nursing experience in current unit (p < .05) were significant but level of nursing education was not. Conclusion Nurse managers are significantly related to unit climates for EBP implementation primarily through their leadership behaviors. Future implementation studies should consider the leadership of nurse managers in creating climates supportive of EBP implementation.https://deepblue.lib.umich.edu/bitstream/2027.42/143195/1/13012_2018_Article_753.pd

Chronic subdural hematoma:A variable clinical picture that asks for tailored treatment

A chronic subdural hematoma is a common neurological disorder that occurs mainly in the elderly. The inciting event is often a minor head trauma and subsequent inflammation may play a role in the pathogenesis. The clinical spectrum can present heterogeneously, and symptom onset and progression can vary from days to weeks. To date surgical evacuation of the subdural collection remains the main treatment approach for symptomatic patients. Evidence is still scarce for dexamethasone as an effective primary conservative treatment strategy. Future research is necessary to elucidate the effect of various pharmacological therapies compared to primary surgery on functional outcome

National survey on the current practice and attitudes toward the management of chronic subdural hematoma

BACKGROUND: Chronic subdural hematoma (CSDH) is a frequent pathological entity in daily clinical practice. However, evidence‐based CSDH‐guidelines are lacking and level I evidence from randomized clinical trials (RCTs) is limited. In order to establish and subsequently implement a guideline, insight into current clinical practice and attitudes toward CSDH‐treatment is required. The aim is to explore current practice and attitudes toward CSDH‐management in the Netherlands. METHODS: A national online survey was distributed among Dutch neurologists and neurosurgeons, examining variation in current CSDH‐management through questions on treatment options, (peri)operative management, willingness to adopt new treatments and by presenting four CSDH‐cases. RESULTS: One hundred nineteen full responses were received (8% of neurologists, N = 66 and 35% of neurosurgeons, N = 53). A majority of the respondents had a positive experience with burr‐hole craniostomy (93%) and with a conservative policy (56%). Around a third had a positive experience with the use of dexamethasone as primary (30%) and additional (33.6%) treatment. These numbers were also reflected in the treatment preferences in the presented cases. (Peri)operative management corresponded among responding neurosurgeons. Most respondents would be willing to implement dexamethasone (98%) if equally effective as surgery and tranexamic acid (93%) if effective in CSDH‐management. CONCLUSION: Variation was found regarding preferential CSDH‐treatment. However, this is considered not to be insurmountable when implementing evidence‐based treatments. This baseline inventory on current clinical practice and current attitudes toward CSDH‐treatment is a stepping‐stone in the eventual development and implementation of a national guideline

External validation of prognostic models predicting outcome after chronic subdural hematoma

Background: Several prognostic models for outcomes after chronic subdural hematoma (CSDH) treatment have been published in recent years. However, these models are not sufficiently validated for use in daily clinical practice. We aimed to assess the performance of existing prediction models for outcomes in patients diagnosed with CSDH. Methods: We systematically searched relevant literature databases up to February 2021 to identify prognostic models for outcome prediction in patients diagnosed with CSDH. For the external validation of prognostic models, we used a retrospective database, containing data of 2384 patients from three Dutch regions. Prognostic models were included if they predicted either mortality, hematoma recurrence, functional outcome, or quality of life. Models were excluded when predictors were absent in our database or available for < 150 patients in our database. We assessed calibration, and discrimination (quantified by the concordance index C) of the included prognostic models in our retrospective database. Results: We identified 1680 original publications of which 1656 were excluded based on title or abstract, mostly because they did not concern CSDH or did not define a prognostic model. Out of 18 identified models, three could be externally validated in our retrospective database: a model for 30-day mortality in 1656 patients, a model for 2 months, and another for 3-month hematoma recurrence both in 1733 patients. The models overestimated the proportion of patients with these outcomes by 11% (15% predicted vs. 4% observed), 1% (10% vs. 9%), and 2% (11% vs. 9%), respectively. Their discriminative ability was poor to modest (C of 0.70 [0.63–0.77]; 0.46 [0.35–0.56]; 0.59 [0.51–0.66], respectively). Conclusions: None of the examined models showed good predictive performance for outcomes after CSDH treatment in our dataset. This study confirms the difficulty in predicting outcomes after CSDH and emphasizes the heterogeneity of CSDH patients. The importance of developing high-quality models by using unified predictors and relevant outcome measures and appropriate modeling strategies is warranted

Safety and technical efficacy of early minimally invasive endoscopy-guided surgery for intracerebral haemorrhage:the Dutch Intracerebral haemorrhage Surgery Trial pilot study

Background: Previous randomised controlled trials could not demonstrate that surgical evacuation of intracerebral haemorrhage (ICH) improves functional outcome. Increasing evidence suggests that minimally invasive surgery may be beneficial, in particular when performed early after symptom onset. The aim of this study was to investigate safety and technical efficacy of early minimally invasive endoscopy-guided surgery in patients with spontaneous supratentorial ICH. Methods: The Dutch Intracerebral Haemorrhage Surgery Trial pilot study was a prospective intervention study with blinded outcome assessment in three neurosurgical centres in the Netherlands. We included adult patients with spontaneous supratentorial ICH ≥10mL and National Institute of Health Stroke Scale (NIHSS) score ≥2 for minimally invasive endoscopy-guided surgery within 8 h after symptom onset in addition to medical management. Primary safety outcome was death or increase in NIHSS ≥4 points at 24 h. Secondary safety outcomes were procedure-related serious adverse events (SAEs) within 7 days and death within 30 days. Primary technical efficacy outcome was ICH volume reduction (%) at 24 h. Results: We included 40 patients (median age 61 years; IQR 51–67; 28 men). Median baseline NIHSS was 19.5 (IQR 13.3–22.0) and median ICH volume 47.7mL (IQR 29.4–72.0). Six patients had a primary safety outcome, of whom two already deteriorated before surgery and one died within 24 h. Sixteen other SAEs were reported within 7 days in 11 patients (of whom two patients that already had a primary safety outcome), none device related. In total, four (10%) patients died within 30 days. Median ICH volume reduction at 24 h was 78% (IQR 50–89) and median postoperative ICH volume 10.5mL (IQR 5.1–23.8). Conclusions: Minimally invasive endoscopy-guided surgery within 8 h after symptom onset for supratentorial ICH appears to be safe and can effectively reduce ICH volume. Randomised controlled trials are needed to determine whether this intervention also improves functional outcome. Trial registration: Clinicaltrials.gov : NCT03608423, August 1st, 2018.</p

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.</p