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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The evacuation of chronic subdural hematoma &#40;cSDH&#41; is one of the most common procedures in neurosurgical practice&#46; The procedure is expected to continue to increase in frequency&#44; since cSDH usually occurs in elderly patients and the demographic development in society leads to a rising number of patients over the age of seventy&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Many of these patients have several comorbidities and are more likely than younger patients to be on antithrombotic drugs at admission&#44; which makes the perioperative management including anesthesia and reversal of antithrombotic drugs more challenging&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The pathophysiology behind this disease is well-understood and there is consensus that the process of the growing hematoma by continuous reabsorption and re-hemorrhage from the circumjacent membrane has to be disrupted&#46; Local anesthesia and minimal invasive approaches are invaluable&#44; in particular for multimorbid patients&#46; However&#44; the ideal surgical technique remains controversial&#46; Mini-craniotomies as well as single or double burr holes are widely used&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">2</span></a> It is also unclear to what extent intracranial membranes must be resected&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> Further&#44; the benefit of the insertion of a subdural drainage appears to be unanimous though it remains debatable how long the drainage should be left in situ&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the evacuation of cSDH is considered an easy and safe procedure&#44; recurrence rates up to 33&#37; are reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">5&#44;6</span></a> Recurrence is often associated with a longer hospital stay and an unfavorable disease course in the elderly and sometimes multimorbid patients&#46; Several series have analyzed the link between the intake of antithrombotic drugs and hematoma recurrence rates and have reported inconsistent results&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">7&#44;8</span></a> Although there are studies that have evaluated the impact of antithrombotic agents on patients suffering from traumatic brain injury&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#44;10</span></a> few studies have addressed the influence of these medications on the clinical outcome of patients with cSDH&#46; In addition&#44; venous thromboembolism prophylaxis in patients with traumatic brain injury has been addressed in previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11&#44;12</span></a> however it has not been discussed in the context of cSDH&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this retrospective series&#44; we introduce the surgical management of cSDH at a single center and investigate the impact of administration of antithrombotic drugs on the clinical outcome of patients surgically treated for cSDH&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">All patients who presented to our department with cSDH proven by CT scan&#44; between June 2008 and June 2013&#44; were identified&#46; Past medical history and neurological function were evaluated and laboratory blood tests were performed at admission&#46; Symptomatic cSDH were assigned to surgical treatment and non-symptomatic cSDH were assigned to conservative treatment&#46; An elevated international normalized ratio &#40;INR&#41; over 1&#46;2 at admission was corrected using vitamin K and prothrombin complex concentrate&#44; while thrombocytopenia was corrected if there was a decrease in platelet count below 50&#44;000 per microliter&#46; Administration of vitamin K in patients of with INR elevation was continued for three days after the procedure&#46; Postoperative blood tests were carried out to monitor INR levels and platelet counts&#46; Patients on antiplatelet medication underwent surgery 5 days after discontinuation of the antiplatelet&#44; unless they were suffering from impaired consciousness&#44; in which case an emergency procedure was performed&#46; Patients who were on phenprocoumon for atrial fibrillation&#44; history of thrombotic embolism in six months prior to admission or for valvular heart disease received a weight adjusted dose of low molecular weight heparin &#40;Enoxaparin sodium&#59; kg&#42;ml&#47;day&#41;&#46; Phenprocoumon is a vitamin K antagonist and belongs to the 4-hydroxycoumarins&#46; In some countries as USA and Spain&#44; warfarin&#44; which is another coumarin&#44; is used instead as a vitamin K antagonist&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For the prevention of venous thromboembolism&#44; all patients received Enoxaparin sodium 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day in case of renal insufficiency&#41; as soon as INR levels were below 1&#46;5&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Only patients who were initially treated surgically were included in this study&#46; The data was evaluated retrospectively according to the local ethical standards&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical management and follow-up</span><p id="par0040" class="elsevierStylePara elsevierViewall">Surgical treatment was performed under local anesthesia&#46; A minority of incompliant patients or those who were not expected to communicate properly during the procedure received general anesthesia&#46; The supine position without pin fixation was used for all patients&#46; After skin incision&#44; a single burr hole was drilled over the maximum width of the hematoma&#46; After coagulation and incision of the dura matter&#44; the hematoma was washed out with warm irrigation using a Nelaton catheter which was inserted in all directions&#44; if possible&#46; In addition&#44; any visible membranes within the cavity of the hematoma were removed&#46; Before closure&#44; a subdural drain &#40;Jackson-Pratt drain&#41; was left in place whenever possible and then removed after 48<span class="elsevierStyleHsp" style=""></span>hours&#46; Bed rest in a supine position was recommended for all patients during the first 48<span class="elsevierStyleHsp" style=""></span>hours postoperatively&#46; CT scans were performed after 48<span class="elsevierStyleHsp" style=""></span>hours&#44; at 4 weeks&#44; and at 3 and 6 months postoperatively&#46; Recurrent hematomas were treated surgically if they were symptomatic or if they increased in size on follow-up CT scans within 6 months after the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical data</span><p id="par0045" class="elsevierStylePara elsevierViewall">Age at surgery&#44; presenting symptoms&#44; administration of antithrombotic agents&#44; history of head trauma&#44; comorbidities&#44; and postoperative complications were assessed by chart reviews&#46; The comorbidities evaluated included diabetes mellitus&#44; atrial fibrillation&#44; arterial hypertension&#44; valvular heart disease ease&#44; coronary heart disease&#44; heart failure and a history of thromboembolic events&#46; Clinical outcome was obtained by questionnaires sent to the patients or telephone interviews and was measured using the modified Rankin Scale &#40;mRS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> Good outcome was defined as mRS 0 to 3 and poor outcome as mRS 4 to 6&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analyses</span><p id="par0050" class="elsevierStylePara elsevierViewall">According to preoperative administration of antithrombotic agents&#44; patients were divided into 3 subgroups&#44; no antithrombotic agents&#44; antiplatelet drug and phenprocoumon&#46; Comparison between these subgroups regarding age&#44; comorbidities and recurrence rates was performed using Kruskal&#8211;Wallis One Way Test and Fisher Exact Test&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Logistic regression was used to identify potential prognosticating factors associated with poor outcome&#46; For all tests&#44; a <span class="elsevierStyleItalic">p</span>-value less than 0&#46;05 was considered significant&#46; Statistical analysis and graphics were performed using IBM SPSS Statistics &#40;v20&#44; IBM Corp&#44; Armonk&#44; New York&#44; USA&#41;&#44; Microsoft Excel &#40;2013&#44; Microsoft Inc&#44; Seattle&#44; Washington&#44; USA&#41; and SigmaPlot &#40;v12&#46;5&#44; Systat Software Inc&#44; Erkrath&#44; Germany&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">249 patients were treated for cSDH at one center during the study period &#40;2008&#8211;2013&#41;&#46; 201 patients were initially assigned for surgical treatment&#44; were available for follow-up and could be included in this study&#46; 48 patients were excluded from the study&#44; either because they were initially treated conservatively or because they refused surgical treatment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">18 patients died after the procedure within a mean interval of 41 weeks &#40;range 2 to 161 weeks&#41;&#46; 5 patients died within 3 weeks after surgery due to postoperative complications including pneumonia&#44; status epilepticus and recurrent bleeding&#46; One patient with a recurrent hemorrhage died 11 weeks after surgery&#46; All other deaths occurred beyond the last CT scan which was performed 6 months after surgery and the leading cause to death was indeterminate&#46; The mean follow-up period in the remaining patients was 81 weeks &#40;range 14 to 242 weeks&#41;&#46; The mean age of the 201 patients &#40;61 female and 140 male&#41; was 72 years &#40;range 25 to 95 years&#41; at the time of operation&#46; A history of fall or head trauma was reported in 85 &#40;42&#46;3&#37;&#41; cases with a mean interval of 6 weeks &#40;range 0&#46;5 to 21 weeks&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Initial symptoms are presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Antithrombotic agents and coagulation testing</span><p id="par0075" class="elsevierStylePara elsevierViewall">Administration of antithrombotic agents was reported in 84 &#40;41&#46;8&#37;&#41; patients upon admission&#58; 38 patients were on aspirin&#44; 3 on clopidogrel&#44; 38 on phenprocoumon&#44; 4 on aspirin plus phenprocoumon&#44; and 1 on clopidogrel plus phenprocoumon&#46; In laboratory studies&#44; 47 patients showed elevated INR values and 6 patients showed thrombocytopenia&#44; which were corrected accordingly prior to the surgical procedure&#46; No further correction of platelet count was necessary postoperatively&#46; Because of impaired consciousness in 4 patients who were on antiplatelet medication&#44; the procedure was performed immediately without the usual 5-day interval&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patient characteristics and comorbidities according to the administration of antithrombotic agents are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Postoperatively&#44; unless there was proof of recurrent hematoma&#44; administration of antiplatelet medication was continued after 2 weeks interval and administration of phenoprocoumon was continued after 4 weeks interval&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Surgical procedure and clinical outcome</span><p id="par0090" class="elsevierStylePara elsevierViewall">In 190 &#40;94&#46;5&#37;&#41; cases&#44; surgery was performed under local anesthesia and in 11 cases &#40;5&#46;5&#37;&#41; it was performed under general anesthesia&#46; 183 &#40;91&#37;&#41; patients had an unilateral hematoma and underwent therefore a single burr hole&#44; while 18 patients &#40;9&#37;&#41; had bilateral hematomas and required two burr holes bilaterally&#46; The procedure-related morbidity was estimated at 4&#46;5&#37; and mortality at 0&#46;5&#37;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">38 patients &#40;18&#46;9&#37;&#41; developed a recurrent hematoma after a mean of 25 days &#40;range 1 to 126 days&#41;&#44; one patient underwent a conservative management and 37 patients &#40;18&#46;4&#37;&#41; underwent a second procedure to evacuate the recurrent hematoma&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The second procedure was performed through the existing burr hole&#44; except in two patients who received a new burr hole&#46; 5 patients suffered a second recurrence und were consequently operated on a third time&#46; At follow-up&#44; good outcome was found in 165 &#40;82&#46;1&#37;&#41; patients and poor outcome was found in 36 patients &#40;17&#46;9&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> demonstrates clinical outcome using mRS according to patient age&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparison and statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patient age and rate of comorbidities in the subgroup of patients with antiplatelet medication didn&#8217;t differ significantly from those in the subgroup with phenprocoumon&#44; but were significantly higher in both subgroups than in the subgroup without antithrombotic agents &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#60;0&#46;001&#41;&#46; No correlation between initial symptoms and patient outcome was observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;204&#41;&#46; None of the comorbidities had influence on clinical outcome &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;067&#44; OR 2&#46;8&#44; 95&#37; CI 0&#46;9&#8211;8&#46;3&#41;&#46; Recurrence of hematoma had no influence on clinical outcome &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;59&#44; OR 1&#46;2&#44; 95&#37; CI 0&#46;53&#8211;3&#46;1&#41;&#46; The intake of phenprocoumon was an independent predictor of poor outcome &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#44; Odds ratio &#40;OR&#41; 2&#46;1&#44; 95&#37; Confidence interval &#40;CI&#41; 1&#46;0&#8211;4&#46;3&#41;&#46; Administration of antiplatelet drug had no measurable influence on outcome &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;135&#44; OR 1&#46;9&#44; 95&#37; CI 0&#46;8&#8211;4&#46;7&#41;&#46; Older patient age &#40;&#62; 72 years&#41; at the time of operation was associated with a poor outcome&#44; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Neither patient age&#44; nor administration of antiplatelet medication or phenprocoumon had an impact on recurrent hematomas &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#44; 0&#46;7 and 0&#46;2&#44; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Mortality and morbidity</span><p id="par0105" class="elsevierStylePara elsevierViewall">In this retrospective study&#44; we evaluated the data of 201 patients who were operated for cSDH using a single burr hole with subdural drain&#46; Although the mean age of 72 years in our patient cohort was similar to other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#8211;16</span></a> the estimated perioperative mortality rate of 0&#46;5&#37; in our series seems to be low comparing with previous studies&#44; which have mortality rates reported between 2&#46;75&#37; and 13&#46;3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;16&#8211;18</span></a> However&#44; the estimated perioperative morbidity rate of 4&#46;5&#37; in the current series is close to the rates reported in the literature&#46; A recurrent hematoma was found in 18&#46;9&#37; of our patients&#44; which is in line with previous studies that included patient numbers similar to that of our study and reported recurrence rates between 17&#37; and 24&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2&#44;7&#44;8&#44;17&#44;19&#8211;21</span></a> These results confirm the safety of a single burr hole under local anesthesia&#44; as well as the use of a Nelaton catheter to evacuate the hematoma and the placement of subdural drain for treatment of cSDH&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Antiplatelet and anticoagulant agents</span><p id="par0110" class="elsevierStylePara elsevierViewall">Administration of antiplatelet or anticoagulant drugs was not a predictor of recurrent hematoma&#46; This finding is a matter of controversy in the literature&#44; as some studies found that the administration of anticoagulants is predictive of recurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">8&#44;19&#44;22&#44;23</span></a> while others did not find any effect of antiplatelet or anticoagulant therapy on recurrence rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">7&#44;20&#44;24</span></a> It is difficult to compare these studies&#44; as they used different surgical techniques to evacuate the hematoma&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Many studies have addressed the clinical outcome of patients with cSDH and the factors that were found to predict a poor outcome included older age&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;19&#44;25</span></a> lower GCS at admission and recurrent hematoma&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> None of these series found an impact of antiplatelet or anticoagulant agents on clinical outcome&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Administration of antiplatelet agents didn&#8217;t influence the outcome in the current series&#44; while administration of phenprocoumon was an independent risk factor of poor outcome&#46; This association has not been reported in the literature to date in the context of cSDH&#46; Foerch et al&#46; presented similar finding regarding intracerebral hemorrhage&#44; as they found that in contrast to oral anticoagulants&#44; pre-treatment with antiplatelet agents is not an independent risk factor of mortality and unfavorable outcome in patients with intracerebral hemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> Grandhi et al&#46; found that the pre-injury use of warfarin&#44; but not antiplatelet agents&#44; increased mortality in elderly traumatic brain injury patients&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> Inui et al&#46; evaluated risk factors for mortality after presentation with a ground-level fall among patients with and without anticoagulant agents and concluded that elderly patients on anticoagulant agents for atrial fibrillation and&#47;or flutter who fall have a greater risk for mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> Also&#44; patients with isolated traumatic subarachnoid hemorrhage and elevated INR were found to be at higher risk of clinical deterioration&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Trauma patients and patients undergoing neurosurgical procedures are at high risk for venous thromboembolism&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;28</span></a> Therefore&#44; venous thromboembolism prophylaxis in patients with cSDH is recommended&#44; especially when anticoagulant agents have been withdrawn perioperatively&#46; Although low molecular weight heparin has not been evaluated regarding its impact on cSDH&#44; there are many studies that have evaluated its use after traumatic brain injury and found no significant risk of expanding intracranial hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Phenprocoumon as a vitamin K antagonist causes the inhibition of synthesis of coagulation factors II&#44; VII&#44; IX and X&#46; The annual rates of major bleeding in patients on vitamin K antagonists in daily care are estimated at up to 8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">31</span></a> Incidence of cSDH has been reported to be elevated in patients who are on aspirin or warfarin &#40;another vitamin K antagonist&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> Since the administration of anticoagulant agents in most patients is linked to serious comorbidities&#44; especially cardiac diseases&#46; Administration of anticoagulants in this series did not correlate with a higher recurrence rate&#44; nevertheless it was associated with a poor outcome&#44; which might be attributed either to a rebleeding that was not detected because it happened beyond the last scheduled CT scan 6 months after surgery or due to other systemic bleeding complications that were not included in our analysis&#59; neurosurgeons have to be aware of the impact of these medications on treatment and outcome of patients with supposedly an easily-treated pathology such as chronic subdural hematoma&#44; and might consider a longer follow-up period in older patients and those who are on anticoagulant medication&#46; In addition&#44; neuro- and trauma surgeons should be aware of many new antithrombotic agents&#44; which are increasingly implemented in daily practice&#44; as their influence on intracranial hemorrhage is still unknown&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">Our results&#44; especially the correlation between the administration of phenprocoumon and poor outcome in patients operated for cSDH&#44; must be interpreted carefully due to the retrospective nature of this study and the wide range of follow-up periods&#46; Larger series will be necessary to confirm our findings&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Administration of phenprocoumon in patients with cardiovascular comorbidities and older age might be predictive of poor outcome in patients with cSDH&#44; while administration of antiplatelet drug did not seem to have an impact on clinical outcome&#46; Neither the administration of phenprocoumon nor single platelet inhibitors influenced the recurrence of subdural hematoma in our patient cohort&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ethical approval</span><p id="par0145" class="elsevierStylePara elsevierViewall">All procedures performed in this study were in accordance with the ethical standards of the local ethics committee and with the 1964 Helsinki declaration and its later amendments&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Hematoma subdural cr&#243;nico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic subdural hematoma &#40;cSDH&#41; is a common pathology encountered in neurosurgical practice&#44; especially in elderly patients&#44; who frequently require antithrombotic agents&#46; The aim of this study was to investigate the influence of antithrombotic agents on recurrence rates and clinical outcomes in patients operated for cSDH&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cohort of patients operated for cSDH at one center during a 5 years period was analyzed retrospectively&#46; Presenting symptoms&#44; coagulation testing&#44; history of antithrombotic agents and comorbidities were obtained from the patient charts&#46; The standard neurosurgical procedure was a single burr hole under local anesthesia with insertion of a subdural drainage&#46; Questionnaires and telephone interviews were used to assess the clinical outcome using the modified Rankin Scale &#40;mRS&#41;&#46; Good outcome was defined as mRS 0 to 3 and poor outcome as mRS 4 to 6&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">201 patients with cSDH underwent initial surgical treatment and were enrolled in the study&#46; The median follow-up was 81 weeks&#46; 41 patients &#40;20&#46;4&#37;&#41; were on antiplatelet drug and 43 &#40;21&#46;4&#37;&#41; were on phenprocoumon&#46; A recurrent hematoma required surgery in 37 patients &#40;18&#46;4&#37;&#41;&#46; A poor outcome was seen in 36 patients &#40;17&#46;9&#37;&#41;&#46; Each of older age and administration of phenprocoumon at admission was an independent risk factor predictive of poor outcome&#44; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#44; respectively&#41;&#41; Administration of antithrombotic agents had no impact on hematoma recurrence&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Administration of phenprocoumon and older age might increase the risk of poor outcome in patients with cSDH&#46; Neither the administration of phenprocoumon nor antiplatelet drug influenced the recurrence rate of subdural hematoma in our patient cohort&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El hematoma subdural cr&#243;nico &#40;HSC&#41; es una enfermedad com&#250;n en la pr&#225;ctica neuro-quir&#250;gica&#44; especialmente en pacientes mayores&#44; quienes requieren con frecuencia agentes anti-tromb&#243;ticos&#46; El objetivo de este estudio fue investigar la influencia de los agentes anti-tromb&#243;ticos en las tasas de recidiva y los resultados cl&#237;nicos en los pacientes operados de HSC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analiz&#243; retrospectivamente una cohorte de pacientes operados de HSC en un &#250;nico centro&#44; durante un periodo de 5 a&#241;os&#46; Se obtuvieron de las historias de los pacientes los s&#237;ntomas de presentaci&#243;n&#44; las pruebas de coagulaci&#243;n&#44; el historial de agentes anti-tromb&#243;ticos y las comorbilidades&#46; El procedimiento quir&#250;rgico est&#225;ndar consisti&#243; en una trepanaci&#243;n bajo anestesia local&#44; con inserci&#243;n de un drenaje subdural&#46; Se utilizaron cuestionarios y entrevistas telef&#243;nicas para valorar el resultado cl&#237;nico mediante la Escala de Rankin modificada &#40;mRS&#41;&#46; El resultado favorable se defini&#243; como el valor de 0 a 3 de mRS&#44; y el resultado desfavorable el valor de 4 a 6&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Doscientos uno pacientes con HSC fueron sometidos a tratamiento quir&#250;rgico inicial&#44; y fueron incluidos en el estudio&#46; El seguimiento medio fue de 81 semanas&#46; A 41 pacientes &#40;20&#44;4&#37;&#41; se les administr&#243; tratamiento anti-plaquetario y a 43 &#40;21&#44;4&#37;&#41; fenprocum&#243;n&#46; El hematoma recurrente requiri&#243; cirug&#237;a en 37 pacientes &#40;18&#44;4&#37;&#41;&#46; Se observaron resultados desfavorables en 36 pacientes &#40;17&#44;9&#37;&#41;&#46; La avanzada edad y la administraci&#243;n de fenprocum&#243;n al ingreso resultaron factores predictivos independientes del resultado desfavorable &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;031&#44; respectivamente&#41;&#46; La administraci&#243;n de agentes anti-tromb&#243;ticos no tuvo impacto sobre la recidiva del hematoma&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La administraci&#243;n de fenprocum&#243;n y la edad avanzada pueden incrementar el riesgo de resultado desfavorable en los pacientes con HSC&#46; Ni la administraci&#243;n de fenprocum&#243;n ni la de f&#225;rmacos anti-plaquetarios influyeron en la tasa de hematomas subdurales en nuestra cohorte de pacientes&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;067&nbsp;\t\t\t\t\t\t\n
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                    "autores" => array:1 [
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                      ]
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                    "titulo" => "Chronic subdural haematomas&#58; a comparative study of an enlarged single burr hole versus double burr hole drainage"
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                        "etal" => true
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                          0 => "D&#46; Pahatouridis"
                          1 => "G&#46;A&#46; Alexiou"
                          2 => "G&#46; Fotakopoulos"
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                  0 => array:2 [
                    "doi" => "10.1007/s10143-012-0412-3"
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                    "autores" => array:1 [
                      0 => array:2 [
                        "etal" => false
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                          0 => "G&#46; Rocchi"
                          1 => "E&#46; Caroli"
                          2 => "M&#46; Salvati"
                          3 => "R&#46; Delfini"
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                    "titulo" => "Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma&#58; a randomised controlled trial"
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                    "titulo" => "Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma"
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                          2 => "N&#46; Watanabe"
                          3 => "S&#46; Inoh"
                          4 => "C&#46; Ochiai"
                          5 => "M&#46; Nagai"
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                    "Revista" => array:7 [
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Vol. 29. Núm. 2.
Páginas 86-92 (marzo - abril 2018)
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Vol. 29. Núm. 2.
Páginas 86-92 (marzo - abril 2018)
Clinical Research
Influence of antithrombotic agents on recurrence rate and clinical outcome in patients operated for chronic subdural hematoma
Influencia de los agentes anti-trombóticos en la tasa de recidiva y el resultado clínico en los pacientes operados de hematoma subdural crónico
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Tammam Abbouda,b,1,
Autor para correspondencia
tammamabboud@gmail.com

Corresponding author.
, Lasse Dührsenb,1, Christina Gibbertb,c, Manfred Westphalb, Tobias Martensb
a University Medical Center Göttingen, Department of Neurosurgery, Germany
b University Medical Center Hamburg-Eppendorf, Department of Neurosurgery, Germany
c Medical Center Eilbek, Department of Spine Surgery, Germany
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Table 1. Patients characteristics, comorbidities and recurrence rates according to the administration of antithrombotic agents.
Table 2. Predictive factors of poor outcome in patients with cSDH.
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Abstract
Introduction

Chronic subdural hematoma (cSDH) is a common pathology encountered in neurosurgical practice, especially in elderly patients, who frequently require antithrombotic agents. The aim of this study was to investigate the influence of antithrombotic agents on recurrence rates and clinical outcomes in patients operated for cSDH.

Methods

A cohort of patients operated for cSDH at one center during a 5 years period was analyzed retrospectively. Presenting symptoms, coagulation testing, history of antithrombotic agents and comorbidities were obtained from the patient charts. The standard neurosurgical procedure was a single burr hole under local anesthesia with insertion of a subdural drainage. Questionnaires and telephone interviews were used to assess the clinical outcome using the modified Rankin Scale (mRS). Good outcome was defined as mRS 0 to 3 and poor outcome as mRS 4 to 6.

Results

201 patients with cSDH underwent initial surgical treatment and were enrolled in the study. The median follow-up was 81 weeks. 41 patients (20.4%) were on antiplatelet drug and 43 (21.4%) were on phenprocoumon. A recurrent hematoma required surgery in 37 patients (18.4%). A poor outcome was seen in 36 patients (17.9%). Each of older age and administration of phenprocoumon at admission was an independent risk factor predictive of poor outcome, (p=0.001 and p=0.031, respectively)) Administration of antithrombotic agents had no impact on hematoma recurrence.

Conclusion

Administration of phenprocoumon and older age might increase the risk of poor outcome in patients with cSDH. Neither the administration of phenprocoumon nor antiplatelet drug influenced the recurrence rate of subdural hematoma in our patient cohort.

Keywords:
Chronic subdural hematoma
Recurrent hematoma
Antiplatelet drug
Anticoagulant drug
Phenprocoumon
Resumen
Introducción

El hematoma subdural crónico (HSC) es una enfermedad común en la práctica neuro-quirúgica, especialmente en pacientes mayores, quienes requieren con frecuencia agentes anti-trombóticos. El objetivo de este estudio fue investigar la influencia de los agentes anti-trombóticos en las tasas de recidiva y los resultados clínicos en los pacientes operados de HSC.

Métodos

Se analizó retrospectivamente una cohorte de pacientes operados de HSC en un único centro, durante un periodo de 5 años. Se obtuvieron de las historias de los pacientes los síntomas de presentación, las pruebas de coagulación, el historial de agentes anti-trombóticos y las comorbilidades. El procedimiento quirúrgico estándar consistió en una trepanación bajo anestesia local, con inserción de un drenaje subdural. Se utilizaron cuestionarios y entrevistas telefónicas para valorar el resultado clínico mediante la Escala de Rankin modificada (mRS). El resultado favorable se definió como el valor de 0 a 3 de mRS, y el resultado desfavorable el valor de 4 a 6.

Resultados

Doscientos uno pacientes con HSC fueron sometidos a tratamiento quirúrgico inicial, y fueron incluidos en el estudio. El seguimiento medio fue de 81 semanas. A 41 pacientes (20,4%) se les administró tratamiento anti-plaquetario y a 43 (21,4%) fenprocumón. El hematoma recurrente requirió cirugía en 37 pacientes (18,4%). Se observaron resultados desfavorables en 36 pacientes (17,9%). La avanzada edad y la administración de fenprocumón al ingreso resultaron factores predictivos independientes del resultado desfavorable (p=0,001 y p=0,031, respectivamente). La administración de agentes anti-trombóticos no tuvo impacto sobre la recidiva del hematoma.

Conclusión

La administración de fenprocumón y la edad avanzada pueden incrementar el riesgo de resultado desfavorable en los pacientes con HSC. Ni la administración de fenprocumón ni la de fármacos anti-plaquetarios influyeron en la tasa de hematomas subdurales en nuestra cohorte de pacientes.

Palabras clave:
Hematoma subdural crónico
Hematoma recurrente
Fármacos anti-plaquetarios
Fármacos anti-coagulantes
Fenprocumón

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