Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors.
OBJECTIVE
This study investigated the incidence and risk factors for the postoperative occurrence of subdural complications, such as a subdural hygroma and resultant chronic subdural hematoma (CSDH), following surgical clipping of an unruptured aneurysm. The critical age affecting such occurrences and follow-up results were also examined.


METHODS
The case series included 364 consecutive patients who underwent aneurysm clipping via a pterional or superciliary keyhole approach for an unruptured saccular aneurysm in the anterior cerebral circulation between 2007 and 2013. The subdural hygromas were identified based on CT scans 6-9 weeks after surgery, and the volumes were measured using volumetry studies. Until their complete resolution, all the subdural hygromas were followed using CT scans every 1-2 months. Meanwhile, the CSDHs were classified as nonoperative or operative lesions that were treated by bur-hole drainage. The age and sex of the patients, aneurysm location, history of a subarachnoid hemorrhage (SAH), and surgical approach (pterional vs superciliary) were all analyzed regarding the postoperative occurrence of a subdural hygroma or CSDH. The follow-up results of the subdural complications were also investigated.


RESULTS
Seventy patients (19.2%) developed a subdural hygroma or CSDH. The results of a multivariate analysis showed that advanced age (p = 0.003), male sex (p < 0.001), middle cerebral artery (MCA) aneurysm (p = 0.045), and multiple concomitant aneurysms at the MCA and anterior communicating artery (ACoA) (p < 0.001) were all significant risk factors of a subdural hygroma and CSDH. In addition, a receiver operating characteristic (ROC) curve analysis revealed a cut-off age of > 60 years, which achieved a 70% sensitivity and 69% specificity with regard to predicting such subdural complications. The female patients ≤ 60 years of age showed a negligible incidence of subdural complications for all aneurysm groups, whereas the male patients > 60 years of age showed the highest incidence of subdural complications at 50%-100%, according to the aneurysm location. The subdural hygromas detected 6-9 weeks postoperatively showed different follow-up results, according to the severity. The subdural hygromas that converted to a CSDH were larger in volume than the subdural hygromas that resolved spontaneously (28.4 ± 16.8 ml vs 59.6 ± 38.4 ml, p = 0.003). Conversion to a CSDH was observed in 31.3% (5 of 16), 64.3% (9 of 14), and 83.3% (5 of 6) of the patients with mild, moderate, and severe subdural hygromas, respectively.


CONCLUSIONS
Advanced age, male sex, and an aneurysm location requiring extensive arachnoid dissection (MCA aneurysms and multiple concomitant aneurysms at the MCA and ACoA) are all correlated with the occurrence of a subdural hygroma and CSDH after unruptured aneurysm surgery. The critical age affecting such an occurrence is 60 years.
Department of Neurosurgery and.|Research Center for Neurosurgical Robotic Systems, Kyungpook National University, Daegu; and.
Jaechan
J
Park
Department of Neurosurgery and.
Jae-Hoon
JH
Cho
Department of Neurosurgery and.
Duck-Ho
DH
Goh
Department of Neurosurgery and.|Research Center for Neurosurgical Robotic Systems, Kyungpook National University, Daegu; and.
Dong-Hun
DH
Kang
Department of Medical Statistics, School of Medicine, Catholic University of Daegu, Republic of Korea.
Im Hee
IH
Shin
Department of Neurosurgery and.
In-Suk
IS
Hamm
D000328:Adult; D000367:Age Factors; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D020200:Hematoma, Subdural, Chronic / Q000453:epidemiology* / Q000209:etiology* / Q000628:therapy; D006801:Humans; D015994:Incidence; D020243:Infarction, Anterior Cerebral Artery / Q000601:surgery; D020244:Infarction, Middle Cerebral Artery / Q000601:surgery; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology* / Q000628:therapy; D012307:Risk Factors; D012737:Sex Factors; D013345:Subarachnoid Hemorrhage / Q000601:surgery; D013353:Subdural Effusion / Q000453:epidemiology* / Q000209:etiology* / Q000628:therapy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
ACoA = anterior communicating artery; CSDH = chronic subdural hematoma; ICA = internal carotid artery; MCA = middle cerebral artery; PACS = picture-archiving and communication system; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage; chronic subdural hematoma; craniotomy; intracranial aneurysm; postoperative complications; subdural hygroma; vascular disorders