title: Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: Associations with initial presentation and clinical outcome.
abstract: The aim of this study is to analyze the association of preoperative usage of angiotensin converting enzyme (ACE) inhibitors with the initial presentation and clinical outcome of patients with chronic subdural hematoma (cSDH). Patients treated for cSDH between 2009 and 2013 at our institution were included in this retrospective case-control study. Medical charts were reviewed retrospectively and data were analyzed using descriptive and inferential statistics. Out of 203 patients (58 females, mean age 73.2years), 53 (26%) patients were on ACE inhibitors before their presentation with cSDH. Median initial hematoma volume in individuals with ACE inhibitors (179.2±standard error of the mean [SEM] 13.0ml) was significantly higher compared to patients without ACE inhibitors (140.4±SEM 6.2ml; p=0.007). There was an increased probability of surgical reintervention in the ACE inhibitor group (12/53, 23% versus 19/153, 12%; p=0.079), especially in patients older than 80years (6/23, 26% versus 3/45, 7%; p=0.026). ACE inhibitors are associated with higher hematoma volume in patients with cSDH and with a higher frequency of recurrences requiring surgery (especially in the very old). We hypothesize that these effects are due to ACE inhibitor induced bradykinin elevation causing increased vascular permeability of the highly vascularized neomembranes in cSDH.
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland. Electronic address: marian.neidert@usz.ch.
authors.forename: Marian C
authors.initials: MC
authors.lastname: Neidert
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Tobias
authors.initials: T
authors.lastname: Schmidt
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Tatyana
authors.initials: T
authors.lastname: Mitova
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Jorn
authors.initials: J
authors.lastname: Fierstra
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Bellut
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Luca
authors.initials: L
authors.lastname: Regli
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Jan-Karl
authors.initials: JK
authors.lastname: Burkhardt
authors.affiliation: Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, CH-8091, Switzerland.
authors.forename: Oliver
authors.initials: O
authors.lastname: Bozinov
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects*; D016022:Case-Control Studies; D005260:Female; D020200:Hematoma, Subdural, Chronic / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D012008:Recurrence; D012189:Retrospective Studies
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: ACE inhibitor; Angiotensin converting enzyme inhibitors; Bradykinin; Chronic subdural hematoma; Hematoma volume; cSDH