Chronic subdural haematomas: a comparative study of an enlarged single burr hole versus double burr hole drainage

Comparison of surgical techniques for the treatment of chronic subdural hematomas: A single‑center case series

Chronic subdural hematoma (CSDH) is one of the most challenging realities in the neurosurgical world. The aim of the present study was to compare different surgical techniques, such as burr hole evacuation with subperiosteal drain or subdural drain and mini-craniotomy, and to review the diverse outcomes on the post-operative clinical state of patients. The present study was a retrospective cohort study with 122 patients with CSDH treated at a single center. The patients were separated into three groups according to the surgical technique used as follows: group 1, two burr holes with the placement of a subperiosteal drain; group 2, single burr hole per hematoma with the placement of an intradural drain; and group 3, mini-craniotomy. The duration of hospitalization, hematoma recurrence, complications, Glasgow coma scale at discharge and mortality were reported as outcome measures. A total of 3 patients succumbed following hematoma evacuation; of these 2 patients were from group 2 and 1 patient was from group 3. The patients from groups 1 and 3 exhibited a significantly lower odds ratio (OR) of hematoma recurrence than patients in group 2 (OR, 0.76; P<0.01; and OR, 0.8; P<0.01, respectively). The patients in group 1 exhibited a significantly lower probability of having a depressed level of consciousness on discharge (OR, 0.249; P=0.031). Group 2 was associated with a statistically significant prolongation of hospitalization. On the whole, the present study demonstrates that multiple burr hole hematoma evacuation with subperiosteal drain placement and mild suction is a very promising technique with very beneficial post-operative outcomes, such as zero mortality, a low CSDH recurrence risk, a reduced period of hospitalization and an improved post-operative quality of life.

Effectiveness of Burr Hole Sizes on Midline Shift and Hematoma Thickness in the Treatment of Chronic Subdural Hematoma

BACKGROUND

The aim of our study was to investigate the effect of the burr hole width on the postoperative chronic subdural hematoma (CSH) thickness and midline shift radiologically.

METHODS

The medical records of 92 patients who had undergone surgery after a diagnosis of CSH between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computed tomography (CT) scans were reviewed, and the thickness of the hematoma and midline shift and the diameters of 2 burr holes opened were measured and recorded. The correlation between the burr hole diameter width and CSH thickness on postoperative CT scans and the improvement in midline shift were investigated statistically.

RESULTS

When the CT scans performed on the first postoperative day and first postoperative month were examined, we found that the preoperative hematoma thickness and midline shift were significantly reduced postoperatively (P < 0.001). A positive significant correlation was found between the improvement in the midline shift, posterior burr hole diameter, and anteroposterior burr hole arithmetic mean (P < 0.001 and P = 0.029, respectively).

CONCLUSIONS

Having examined the current surgical techniques in the treatment of CSH, we found that an increase in the burr hole craniostomy width, especially the posterior burr hole craniostomy width, contributed to the improvement in the midline shift.

Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses

BACKGROUND

Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence.

METHODS

We searched Embase, Web of Science, PubMed, and Cochrane Library from their establishment to September 2020. Reports on randomized, prospective, retrospective, and overall observational studies on the management of surgical patients with CSDH were searched, and an independent reviewer performed research quality assessment. Factors that affect the postoperative recurrence of CSDH were extracted: social demographics, drugs (as the main or auxiliary treatment), surgical management, imaging, and other risk factors. We evaluated the recurrence rate of each risk factor. A random effect model was used to perform a meta-analysis, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded.

FINDINGS

In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence. The classification of evidence can help clinicians identify significant risk factors for the postoperative recurrence of CSDH.

INTERPRETATION

Only few associations were supported by high-quality evidence. Factors with high-quality evidence may be important for treating and preventing CSDH recurrence. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods.

FUNDING

No funding was received.

Chronic Subdural Hematoma (cSDH): A review of the current state of the art

Introduction

Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies.

Research question

What is the state of the art of cSDH management.

Material and methods

Review.

Results

Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs.

Discussion and conclusion

While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment.

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Incidence of cSDH is rising, partly due to the aging population and increased antithrombotic use.

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cSDH occurs bilaterally in 9–22% of cases.

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Recurrence remains the principle complication and has been estimated at 9–33%.

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Risk factors for recurrence include old age and bilateral cSDHs.

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MMA embolization may reduce recurrence, but its efficacy and target population remain unclear.

Single versus Double Burr Hole for Drainage of Chronic Subdural Hematoma: Randomized Controlled Study

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical emergencies. Most neurosurgeons currently drained CSDH through single or double burr holes; however, few studies have compared the 2 approaches to drainage. The aim of this study is to compare the recurrent rate following double and single burr hole for CSDH in our practice.

METHODS

This is a randomized controlled study from January 2015 to December 2019 in a neurosurgical unit in Kaduna, Nigeria. All patients with imaging diagnosis of subacute or chronic subdural hematoma who enrolled in the study had either a single or double burr hole. Patients were followed up for 6 months after surgery to assess for recurrence. Data were analyzed using SPSS version 25 for Windows. The Fisher exact test was performed to compare the 2 treatment groups. A 2-sided P value < 0.05 was considered statistically significant.

RESULTS

A total of 192 patients were enrolled in the study with 99 in the single-burr hole group and 93 in the double burr-hole group. The overall recurrence rate in this study was 2.6%. The recurrence rate in the single arm was 3%, and in the double arm it was 2.2%. There was no statistically significant difference in recurrence between the 2 groups (P = 1.000).

CONCLUSIONS

A single burr hole is as efficacious as a double burr hole in terms of relief of symptoms and recurrence, and it has a shorter duration of surgery.

Use of siphon irrigation during burr-hole craniostomy to evacuate chronic subdural hematoma: A retrospective cohort comparison study

Burr-hole craniostomy (BHC) is a widely accepted treatment for chronic subdural hematomas (CSDHs). This study adopted siphon irrigation to evacuate CSDHs and investigated its efficacy and safety as compared with the traditional irrigation used in BHC.A retrospective cohort study was conducted at a center between January 2017 and December 2018. The data of 171 patients who underwent burr-hole craniostomy for CSDH were collected and analyzed. A total of 68 patients underwent siphon irrigation (siphon group) and 103 patients were treated by a traditional method (control group). A follow-up was conducted 6 months after the surgery.No significant difference was observed in the baseline characteristics and preoperative computed tomography (CT) features of the 2 groups (P > .05). The postoperative CT features of the siphon group, which included the volume of hematoma evacuation (P = .034), hematoma evacuation rate (P < .001), recovery rate of the midline shift (P = .017), and occurrence of pneumocephalus (P = .037) were significantly different and better than those of the control group. The length of hospital stay after surgery of the siphon group was significantly shorter than that of the control group (P = .015). The Markwalder score of the siphon group was significantly superior to that of the control group on postoperative day 1 (P = .006). Although the recurrence rate in the siphon group (2/68, 2.5%) was lower than that in the control group (11/103, 8.9%), no statistically significant difference was observed between them (P = .069). Moreover, no significant differences were observed in terms of complications and mortality rate between the 2 groups.There was no significant difference in the recurrence rate between the groups that underwent siphon irrigation and traditional irrigation. However, in comparison, siphon irrigation can better improve postoperative CT features, promote early recovery of neurological dysfunction after surgery, and shorten the length of hospital stay. This indicates that siphon irrigation may be a better therapeutic option in BHC for CSDH.

Single Versus Double Burr Hole Craniostomy in Surgical Treatment of Chronic Subdural Hematoma: A Meta-Analysis

BACKGROUND

Chronic subdural hematoma (cSDH) is one of the most common illnesses seen in neurosurgery departments worldwide. For surgical treatment, some neurosurgeons prefer single burr hole craniostomy (SBHC), whereas others prefer double burr hole craniostomy (DBHC). We performed a meta-analysis to investigate whether DBHC is associated with increased risks of recurrence, complications and mortality compared with SBHC in patients with cSDH.

METHODS

Retrospective observational trial or randomized controlled trial (RCT) studies concerning burr hole craniostomy to treat cSDH were systematically identified through a search of electronic databases: PubMed, Web of Science, Embase, and Cochrane. Inclusion and exclusion criteria were defined for the eligible studies. The random fixed-effects model was used when heterogeneity was indicated; otherwise, a fixed-effects model was adopted.

RESULTS

This meta-analysis included 12 studies, 3 of which were RCTs. Our findings can be summarized as follows. First, SBHC did not increase the risk of recurrence compared with DBHC in patients with cSDH (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.92-1.78; P =0.07). Second, DBHC was not associated with an increased complication rate compared with SBHC in patients with cSDH (OR, 0.74; 95% CI, 0.20-2.76; P = 0.11). Third, DBHC did not increase mortality compared with SBHC in patients with cSDH (OR, 1.38; 95% CI, 0.55-3.46; P = 0.58).

CONCLUSIONS

This meta-analysis demonstrates that there are no significant differences in recurrence rate, complication rate, and morbidity between SBHC and DBHC in the treatment of patients with cSDH.

A retrospective analysis of chronic subdural haematoma recurrence rates following burr hole trephination versus minicraniotomy

The aim of this study was to determine the subdural haematoma recurrence rate in patients with symptomatic chronic subdural haematomas (CSDH) treated with either burr hole trephination (BHT) or minicraniotomy (MC) and to determine whether a statistically significant difference exists between the two techniques. A retrospective analysis of all consecutive patients with symptomatic CSDH treated with BHT or MC at the John Hunter Hospital Neurosurgery Department between July 2004 and July 2016 was performed. After inclusion/exclusion criteria were applied, 368 patients with 439 CSDHs were eligible. Baseline demographic data was recorded for all patients. Statistical analysis was performed assessing haematoma recurrence as the primary outcome and mortality as a secondary outcome. Three hundred and sixty eight patients were included in the study, with 225 being treated with MC and 143 with BHT. Baseline demographic data was similar between the two groups. The recurrence rate for patients treated with BHT was 0.13 (95% CI 0.08-0.18), versus 0.18 (95% CI 0.13-0.23) in the MC group. This difference was not statistically significant. Similarly, there was no statistically significant difference in mortality rates between the two groups. The mortality rate in the BHT group was 0.09 (95% CI 0.05-0.14) versus 0.09 (95% CI 0.05-0.13) in the MC group. In our series there was no difference in recurrence rates or mortality rates between the two groups, suggesting MC is an effective alternative to BHT in the management of symptomatic CSDH.

Radiolological predictors of recurrence of chronic subdural hematoma

Objective:

Chronic subdural hematoma is one of the most common clinical entities encountered in daily neurosurgical practice. Considerable recurrence rates have been reported for chronic subdural hematoma following surgical evacuation. Many studies have suggested various radiological factors that may be associated with the recurrence of CSDH. However, the results are inconsistent. This study focuses on determining the radiological factors predictive of chronic subdural hematoma recurrence.

Methods:

A retrospective analysis of 113 patients diagnosed with chronic subdural hematoma who were surgically treated between August 2013 and December 2014 was performed. The radiological features were analyzed to clarify the correlation between these radiological factors and postoperative recurrence of chronic subdural hematoma.

Results:

Twenty patients (17.7%) experienced recurrence. Chronic subdural hematoma recurrence was found to be significantly associated (p<0.05) with preoperative hematoma thickness ≥ 20 mm. Midline shift, hematoma density and bilaterality were not significantly associated with recurrence. Post operative drainage also significantly (p<0.05) reduced chronic subdural hematoma recurrence.

Conclusion:

Preoperative hematoma thickness ≥ 20 mm is an independent predictor of recurrence of chronic subdural hematoma. Postoperative drainage also significantly reduces chronic subdural hematoma recurrence.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom

OBJECTIVE

Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH.

METHODS

Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4–6) at NSU discharge < 30%.

RESULTS

Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not.

CONCLUSIONS

This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Prognostic factors in chronic subdural hematoma: results from a monocentric consecutive surgical series of 605 patients

BACKGROUND

The study of age-related diseases like chronic subdural hematoma (CSDH) is of high interest, considered the general ageing of the population. This investigation aimed to identify the main clinical characteristics of CSDH patients, to evaluate the impact of the disease on quality of life, its treatment and comorbidities/complications and to compare our data with other surgical series published over the past 5 years.

METHODS

A retrospective cohort study including all consecutive patients operated for CSDH between January 1, 2006 and December 31, 2013 at the Unit of Neurosurgery of our hospital was carried out.

RESULTS

605 patients were included in the study (66.0% male, mean age 77.5±10.5 years). History of brain trauma was reported in 65.6%. Common comorbidities were hypertension (59.0%), cardiopathies (36.0%), and previous stroke (23.6%). Clotting and coagulation alterations were present in 27.2% and 17.0%, respectively. In 24.0% of cases, the hematoma was bilateral. 17.3% had more than one surgery. Length of stay was of 14.8±10.1 days. Baseline Karnofsky Performance Score (KPS), presurgical KPS, and KPS at discharge were 87.7±14.9, 64.9 ±19.8 and 76.7±27.2, respectively. A complete recovery was observed in 62.9% of patients. Mortality rate during hospitalization was 7.4%.

CONCLUSIONS

The knowledge of clinical and surgical factors which might impact on the clinical outcomes could help to better manage patients with CSDH, which represents a surgically "simple" but, indeed, not trivial disease.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom

OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

To Drain or Two Drains: Recurrences in Chronic Subdural Hematomas

BACKGROUND

Chronic subdural hematoma (cSDH) is a common neurosurgical condition, with an estimated incidence of 3-15.5 per 100,000 people, with significantly higher rates in the elderly population. Recurrence rates range from 2%-37% after surgical drainage. Studies have shown that leaving a drain postoperatively can reduce recurrence rates, but studies have not looked at whether there is a difference between leaving 1 or 2 drains.

METHODS

We analyzed 215 patients undergoing burr hole drainage for 261 cSDHs in terms of preoperative comorbidities and postoperative drain placement.

RESULTS

Recurrences requiring repeat evacuation occurred in 6.1% overall, in 6/110 patients (5.5%) with 1 burr hole, and in 11/151 patients (7.3%) who had 2 burr holes, which was not significantly different. Recurrences occurred in 1/15 patients (6.7%) with no drain, 13/210 patients (6.2%) with 1 drain, and in 2/36 patients (5.6%) with 2 drains, which was also not statistically significant. The only medical comorbidity associated with an increased risk of recurrence was liver disease (P = 0.014).

CONCLUSIONS

This study demonstrates that neither the number of burr holes nor the number of drains left after a burr hole drainage of cSDH appear to affect recurrence rates, whereas liver disease does make recurrence more likely.

Comparison of the Outcomes and Recurrence with Three Surgical Techniques for Chronic Subdural Hematoma: Single, Double Burr Hole, and Double Burr Hole Drainage with Irrigation

Objective

Chronic subdural hematoma (CSDH), a disease commonly encountered by neurosurgeons, is treated by burr hole drainage (BHD). However, the optimal surgical technique among the three types of BHD has not been determined.

Methods

We conducted a retrospective study on BHD performed on 93 patients who were diagnosed with CSDH. The subjects were divided into three groups based on the surgical technique performed: single BHD without irrigation (Group A, n=31), double BHD without irrigation (Group B, n=32), and double BHD with irrigation (Group C, n=30). The clinical factors, radiological factors and recurrences were compared between the three groups. Moreover, independent factors affecting the recurrence were analyzed.

Results

The change in hematoma thickness was 29.77±7.94%, 49.73±12.87%, and 75.29±4.32% for Group A, B, and C, respectively, while the change in midline shift was 40.81±15.47%, 51.78±10.94%, and 56.16±16.16%, respectively. Thus, Group C showed the most effective for resolution of hematoma and midline shift (p<0.05). Group A, B, and C had 12 cases (38.7%), 8 cases (25.0%), and 3 cases (10.0%) of recurrences, respectively. Group C had a statistically significantly fewer recurrence rate than Group A (p<0.05). Double burr hole, irrigation, and coagulopathy were each identified as independent factors that reduce recurrence (p<0.05).

Conclusion

Among the three techniques, the double BHD with saline irrigation resulted in the fewest recurrences. It is probably the most effective technique for preventing the recurrence of CSDH.

Acute intracranial bleeding and recurrence after bur hole craniostomy for chronic subdural hematoma

OBJECT

There is inconsistency among the perioperative management strategies currently used for chronic subdural hematoma (cSDH). Moreover, postoperative complications such as acute intracranial bleeding and cSDH recurrence affect clinical outcome of cSDH surgery. This study evaluated the risk factors associated with acute intracranial bleeding and cSDH recurrence and identified an effective perioperative strategy for cSDH patients.

METHODS

A retrospective study of patients who underwent bur hole craniostomy for cSDH between 2008 and 2012 was performed.

RESULTS

A consecutive series of 303 cSDH patients (234 males and 69 females; mean age 67.17 years) was analyzed. Postoperative acute intracranial bleeding developed in 14 patients (4.57%) within a mean of 3.07 days and recurrence was observed in 37 patients (12.21%) within a mean of 31.69 days (range 10–104 days) after initial bur hole craniostomy. The comorbidities of hematological disease and prior shunt surgery were clinical factors associated with acute bleeding. There was a significant risk of recurrence in patients with diabetes mellitus, but recurrence did not affect the final neurological outcome (p = 0.776). Surgical details, including the number of operative bur holes, saline irrigation of the hematoma cavity, use of a drain, and type of postoperative ambulation, were not significantly associated with outcome. However, a large amount of drainage was associated with postoperative acute bleeding.

CONCLUSIONS

Bur hole craniostomy is an effective surgical procedure for initial and recurrent cSDH. Patients with hematological disease or a history of prior shunt surgery are at risk for postoperative acute bleeding; therefore, these patients should be carefully monitored to avoid overdrainage. Surgeons should consider informing patients with diabetes mellitus that this comorbidity is associated with an increased likelihood of recurrence.

The epidemiology, risk factors, and impact on hospital mortality of status epilepticus after subdural hematoma in the United States

Introduction

Subdural hematoma (SDH) is a well described risk factor in the development of Status Epilepticus (SE), however the epidemiology of SE after SDH is unknown. In this study, we sought to determine the epidemiology of SE, the prevalence of risk factors, and impact on hospital mortality using a large administrative dataset.

Methods

Data was derived from the Nationwide Inpatient Sample from 1988 through 2011. We queried the NIS database for patients older than 18 years, with a diagnosis of SDH and SE. Diagnoses were defined by ICD 9 CM codes 432.1, 852.2, 852.3 and 345.3 for SE. Adjusted incidence rates of admission and prevalence proportions were calculated. Multivariate logistic models were then fitted to assess for the impact of status epilepticus on hospital mortality.

Results

Over the 23-year period, we identified more than 1,583,255 admissions with a diagnosis of SDH. The prevalence of SE in this cohort was 0.5% (7,421 admissions). The population adjusted incidence rate of admissions of SDH increased from 13/100,000 in 1988 to 38/100,000 in 2011. The prevalence of SE in SDH, increased from 0.5% in 1988 to 0.7% in 2011. In hospital mortality of patients with SDH and without SE decreased from 17.9% to 10.3% while in hospital mortality of patients with SDH and SE did not statistically change. Mortality increased over the same period (2.3/100,000 in 1988 to 3.9/100.000 in 2011) and the diagnosis of SE increased mortality in this cohort (OR 2.17, p < 0.0001). The risk of SE remained stable throughout the study period, but was higher among older patients, blacks, and in those with respiratory, metabolic, hematological, and renal system dysfunction.

Conclusion

Our study demonstrates that the incidence of admissions of SDH is increasing in the United States. Despite a decline in the overall SDH related mortality, SE increased the risk of in-hospital death in patients with a primary diagnosis of SDH.

Proposal for a prospective multi-centre audit of chronic subdural haematoma management in the United Kingdom and Ireland

BACKGROUND. Chronic subdural haematoma (CSDH) is a common condition that increases in incidence with rising age. Evacuation of a CSDH is one of the commonest neurosurgical procedures; however the optimal peri-operative management, surgical technique, post-operative care and the role of adjuvant therapies remain controversial. AIM. We propose a prospective multi-centre audit in order to establish current practices, outcomes and national benchmarks for future studies. METHODS. Neurosurgical units (NSU) in the United Kingdom and Ireland will be invited to enrol patients to this audit. All adult patients aged 16 years and over with a primary or recurrent CSDH will be eligible for inclusion. OUTCOME MEASURES AND ANALYSIS. The proposed outcome measures are (1) clinical recurrence requiring re-operation within 60 days; (2) modified Rankin scale (mRS) score at discharge from NSU; (3) morbidity and mortality in the NSU; (4) destination at discharge from NSU and (5) length of stay in the NSU. Audit standards have been derived from published systematic reviews and a recent randomised trial. The proposed standards are clinical recurrence rate < 20%; unfavourable mRS (4-6) at discharge from NSU < 30%; mortality rate in NSU < 5%; morbidity rate in NSU < 10%. Data will be submitted directly into a secure online database and analysed by the study's management group. CONCLUSIONS. The audit will determine the contemporary management and outcomes of patients with CSDH in the United Kingdom and Ireland. It will inform national guidelines, clinical practice and future studies in order to improve the outcome of patients with CSDH.