Hiroyuki Toi

Chronic Subdural Hematoma in Elderly Patients: Is This Disease Benign?

As the world population becomes progressively older, the overall incidence of chronic subdural hematoma (CSDH) is increasing. Peak age of onset for CSDH has also increased, and recently the 80-year-old level has a peak. Many patients with CSDH have had prior treatment with anticoagulants and antiplatelet drugs, which have an accompanying risk of CSDH. In elderly patients with CSDH, symptoms of cognitive change (memory disturbance, urinary incontinence, and decreased activity) and disturbance of consciousness at admission were more frequent compared to younger patients with CSDH. The literature actually offers conflicting advice regarding CSDH treatment; however, burr hole surgery with drainage under local anesthesia is the most common surgical procedure, even in elderly patients. The recurrence rate of CSDH has not decreased over recent decades, and it has ranged from 0.36–33.3%. Outcomes in patients over 75 years old was significantly worse than for those younger than 75. Moreover, long-term outcomes for elderly patients with CSDH are poor. CSDH in the elderly is no longer a benign disease. In the future, it will be important for us to understand the mechanisms of onset and recurrence of CSDH and to develop more effective medical treatments and noninvasive surgical techniques for elderly patients.

Surgical results of lumbar interbody fusion using calcium phosphate cement.

Clinical and radiological outcomes of lumbar interbody fusion using artificial fusion cages filled with calcium phosphate cements (CPCs) were retrospectively reviewed. Between 2002 and 2011, 25 patients underwent lumbar interbody fusion at Tokushima University Hospital, and 22 patients were enrolled in this study. Of these, 5 patients received autologous local bone grafts and 17 received CPC. Japan Orthopedic Association (JOA) score was used for clinical outcome assessments. Lumbar radiography and computed tomography (CT) were performed at 12, 24 months and last follow-up period to assess bony fusion. The mean JOA score of all patients improved from 9.3 before surgery to 21.0 at 24 months after surgery. Fusion had occurred in 5 of 5 patients in the local bone graft group and in 16 of 17 patients in CPC group at 24 months postoperatively. No surgically related complication was occurred in both groups. CPC is a useful and safe graft material for lumbar interbody fusion.

Plaque Characteristics of Patients with Symptomatic Mild Carotid Artery Stenosis

BACKGROUNDnCarotid revascularization may be considered for severe stenosis, but its use for symptomatic mild stenosis (<50%) with vulnerable plaque or ulcer remains uncertain. The characteristics of patients with symptomatic mild stenosis who underwent revascularization are reviewed.nnnMETHODSnThe subjects of this study were 18 patients with symptomatic mild stenosis (<50%) on angiography from among 175 patients who underwent revascularization in our department. The plaques were evaluated by black-blood magnetic resonance imaging (BB-MRI) and ultrasonography (US) and classified into 2 types: type 1 (nu2009=u200915), a lesion with an ulcer or mobile plaque or thrombosis on angiography or US; and type 2 (nu2009=u20093), a lesion without any of the above. Fourteen patients underwent carotid endarterectomy (CEA), and 4 patients underwent carotid artery stenting.nnnRESULTSnThe stenosis on angiography was 27.2%u2009±u200910.7 (5%-41%), and the area carotid artery stenosis rate on US was 69.8u2009±u200914.5% (44.5%-97%). The stenosis rate of these 2 methods was not at all correlated. In type 1 plaque that underwent CEA, 10 of 11 patients had vulnerable plaque by histopathology, and 1 patient had thrombus on the plaque by operative findings. In type 2 plaque that underwent CEA, all patients had vulnerable plaque by histopathology. During the follow-up period, none of the patients had restenosis or stroke.nnnCONCLUSIONSnThe findings of US and BB-MRI in patients with symptomatic mild stenosis (<50%) on angiography are important for determining treatment. If BB-MRI or US shows the findings of vulnerable plaque in mild stenosis, surgical treatment may be considered for these patients.

Determining if Cerebrospinal Fluid Prevents Recurrence of Chronic Subdural Hematoma: A Multi-Center Prospective Randomized Clinical Trial

Over the decades, the problem of postoperative recurrence of chronic subdural hematoma (CSDH) has not been resolved. The objective of our study was to investigate whether the recurrence rate of CSDH is decreased when artificial cerebrospinal fluid (ACF) is used as irrigation solution for CSDH surgery. The present study was a multi-center, prospective, randomized, open parallel group comparison test of patients enrolled from 10 hospitals in Japan. Eligible patients with CSDH were randomly assigned to undergo burr hole drainage with either normal saline (NS) or ACF irrigation. The primary end-point was postoperative recurrence of ipsilateral CSDH. A total of 402 patients with newly diagnosed CSDH were enrolled during the study period. After applying inclusion and exclusion criteria, and taking into consideration cases lost to follow-up, our final study cohorts consisted of 177 ACF patients and 165 NS patients, representing 85.7% of the initial cohort. The overall recurrence rate was 11.4%, occurring in 39 of the 342 analyzed patients during 90 days of follow-up. Recurrence rates in the ACF and NS groups were 11.9% (21 of 177) and 10.9% (18 of 165), respectively. No significant difference was evident between groups (pu2009=u20090.87). In addition, no significant difference in time to recurrence was seen between groups (pu2009=u20090.74). No serious adverse effects related to irrigation fluid were seen in either group. Regarding the irrigation fluid for CSDH surgery, no differences in recurrence rate or time to recurrence were seen between the ACF and NS groups. However, ACF offers sufficient safety as irrigation fluid for CSDH.