When the Drain Hits the Brain

Quantitative Assessment of Brain Expansion After Evacuation of Chronic Subdural Hematoma as a Predictor of Recurrence

BACKGROUND

A lack of brain expansion is considered a risk factor for recurrence after evacuation of a chronic subdural hematoma (CSDH). To the best of our knowledge, no studies have reported on objective measurement of brain expansion after evacuation of a CSDH.

METHODS

We performed a retrospective analysis of prospectively collected data of patients undergoing 2 burr hole evacuation of a CSDH. We measured the depth of the brain surface from the frontal burr hole dural opening after hematoma evacuation using a specially devised measuring tool. Other predictors analyzed for recurrence of hematoma were age, gender, a history of hypertension, the use of anticoagulant and/or antiplatelet agents, Glasgow coma scale score at presentation, unilateral or bilateral hematoma, computed tomography appearance, and hematoma thickness.

RESULTS

Among 88 patients who underwent hematoma evacuation, 3 (3.4%) underwent surgery for recurrence. The significant factors associated with recurrence were the presence of bilateral hematoma (P = 0.001), hematoma width >2.3 cm (P = 0.04), gradation type of hematoma on the computed tomography scan (P = 0.03), and the depth of the brain after hematoma evacuation (P = 0.02). The brain expanded less in those with recurrence, with a mean depth of the brain of 18 ± 6 mm versus 7.27 ± 7.8 mm in those without recurrence.

CONCLUSIONS

Evacuation of a CSDH through 2 burr holes, along with copious irrigation and bed rest for 3 days, resulted in a very low recurrence rate without the use of a drain. A lack of brain expansion might be a predictor of recurrence. To the best of our knowledge, this is the first study to quantitatively measure the depth of the brain at surgery in patients undergoing surgery for CSDH.

Passive or active drainage system for chronic subdural haematoma-a single-center retrospective follow-up study

BACKGROUND

Postoperative drainage systems have become a standard treatment for chronic subdural hematoma (CSDH). We previously compared treatment results from three Scandinavian centers using three different postoperative drainage systems and concluded that the active subgaleal drainage was associated with lower recurrence and complication rates than the passive subdural drainage. We consequently changed clinical practice from using the passive subdural drainage to the active subgaleal drainage.

OBJECTIVE

The aim of the present study was to assess a potential change in reoperation rates for CSDH after conversion to the active subgaleal drainage.

METHODS

This single-center cohort study compared the reoperation rates for recurrent same-sided CSDH and postoperative complication rates between patients treated during two study periods (passive subdural drainage cohort versus active subgaleal drainage cohort).

RESULTS

In total, 594 patients were included in the study. We found no significant difference in reoperation rates between the passive subdural drain group and the active subgaleal drain group (21.6%, 95% CI 17.5-26.4% vs. 18.0%, 95% CI 13.8-23.2%; p = 0.275). There was no statistical difference in the rate of serious complications between the groups. The operating time was significantly shorter for patients operated with the active subgaleal drain than patients with the passive subdural drain (32.8 min, 95% CI 31.2-34.5 min vs. 47.6 min, 95% CI 44.7-50.4 min; p < 0.001).

CONCLUSIONS

Conversion from the passive subdural to the active subgaleal drainage did not result in a clear reduction of reoperation rates for CSDH in our center.

Reducing morbidity associated with subdural drain placement after burr-hole drainage of unilateral chronic subdural hematomas: a retrospective series comparing conventional and modified Nelaton catheter techniques

PURPOSE

Placement of a subdural drain after burr-hole drainage of chronic subdural hematoma (cSDH) significantly reduces risk of its recurrence and lowers mortality at 6 months. Nonetheless, measures to reduce morbidity related to drain placement are rarely addressed in the literature. Toward reducing drain-related morbidity, we compare outcomes achieved by conventional insertion and our proposed modification.

METHODS

In this retrospective series from two institutions, 362 patients underwent burr-hole drainage of unilateral cSDH with subsequent subdural drain insertion by conventional technique or modified Nelaton catheter (NC) technique. Primary endpoints were iatrogenic brain contusion or new neurological deficit. Secondary endpoints were drain misplacement, indication for computed tomography (CT) scan, re-operation for hematoma recurrence, and favorable Glasgow Outcome Scale (GOS) score (≥ 4) at final follow-up.

RESULTS

The 362 patients (63.8% male) in our final analysis included drains inserted in 56 patients by NC and 306 patients by conventional technique. Brain contusions or new neurological deficits occurred significantly less often in the NC (1.8%) than conventional group (10.5%) (P = .041). Compared with the conventional group, the NC group had no drain misplacement (3.6% versus 0%; P = .23) and significantly fewer non-routine CT imaging related to symptoms (36.5% versus 5.4%; P < .001). Re-operation rates and favorable GOS scores were comparable between groups.

CONCLUSION

We propose the NC technique as an easy-to-use measure for accurate drain positioning within the subdural space that may yield meaningful benefits for patients undergoing treatment for cSDH and vulnerable to complication risks.

Subperiosteal/subgaleal drainage vs. subdural drainage for chronic subdural hematoma: A meta-analysis of postoperative outcomes

BACKGROUND

Chronic subdural hematoma (CSDH) is commonly treated via surgical removal of the hematoma, placement of a routine indwelling drainage tube, and continuous drainage to ensure that the blood does not re-aggregate following removal. However, the optimal location for placement of the drainage tube remains to be determined.

OBJECTIVES

To aid in establishing a reference for selecting the optimal method, we compared the effects of different drainage tube placements on CSDH prognosis via a systematic review and meta-analysis of previous clinical studies.

DATA SOURCES

PubMed, Embase, and Cochrane databases.

STUDY ELIGIBILITY CRITERIA

We searched for clinical studies comparing the outcomes of subperiosteal/subgaleal drainage (SPGD) and subdural drainage (SDD) for CSDH published in English prior to April 1, 2022.

PARTICIPANTS

The final analysis included 15 studies involving 4,318 patients.

RESULTS

Our analysis of the pooled results revealed no significant differences in recurrence rate between the SDD and SPGD groups. We also observed no significant differences in mortality or rates of postoperative complications (infection, pneumocephalus, or epilepsy) between the SDD and SPGD groups.

CONCLUSIONS

These results suggest that the choice of SDD vs. SPGD has no significant effect on CSDH prognosis, highlighting SPGD as an alternative treatment option for CSDH.

Complications From Subdural Drains in Burr Hole Drainage of Chronic and Subacute Subdural Haematomas: A Single-Centre Experience

Introduction The use of drains following the burr-hole evacuation of chronic (CSDH) and subacute subdural haematomas (SASDH) is a well-established practice offering a significant reduction in recurrence rates and improvement of survival. The purpose of this work is to investigate the complication rate of subdural drains following the burr-hole evacuation of CSDH and SASDH. Methods A retrospective review of the clinical records of all patients managed surgically for CSDH or SASDH was conducted. Patients over 18 years, that met the criteria for surgical evacuation, were included in this study. Patients admitted for CSDH or SASDH but managed either conservatively or with craniotomy were excluded from further analysis. Results A total of 97 cases, with a mean age at the time of diagnosis of 78.25 years were identified in which 122 drains were used. Three complications, two acute subdural haematomas, and one case of drain-associated seizures were identified, yielding an overall complication rate of 3%. Conclusion The use of intradural drains is associated with a small, yet not negligible, possibility of serious complications.

Seizure after surgical treatment of chronic subdural hematoma—Associated factors and effect on outcome

Introduction

Chronic subdural hematoma (cSDH) is becoming more prevalent due to population aging and the increasing use of antithrombotic drugs. Postoperative seizure in cSDH have a negative effect on outcome, and there currently no consensus regarding prophylactic anti-epileptic drug (AED) treatment. The objective of this study was to evaluate predisposing and triggering factors associated with postoperative epileptic seizure in patients with cSDH.

Methods

All patients, who were surgically treated for cSDH in a single tertiary care center between 2015 and 2019, were considered for inclusion. Relevant patient- and hematoma-specific characteristics were retrospectively extracted from hospital records. Paroxysmal events categorized by the treating physician as suspected postoperative seizures were noted. The clinical outcome was extracted from the last available follow-up visit and classified according to the Glasgow outcome scale (GOS).

Results

Of the included 349 patients, 54 (15.5%) developed suspected postoperative epileptic complications in the form of early seizure (≤ 7 days) in 11 patients (3.2%) and late seizure (&gt;7 days) in 43 patients (12.3%). In the logistic regression analysis, solely depressed brain volume (supratentorial volume (ml) not filled with re-expanded brain) was independently associated with postoperative seizure (odds ratio [OR] 1.006, 95% CI: 1.001–1.011; p = 0.034). The occurrence of postoperative seizure (OR 6.210, 95% CI: 2.704–14.258; p &lt; 0.001) and preoperative Markwalder grading (OR 2.919, 95% CI: 1.538–5.543; p = 0.001) were independently associated with unfavorable (GOS1−3) outcome.

Conclusion

Larger postoperative depressed brain volume was the only factor independently associated with suspected postoperative seizure, and it could help identify a subgroup of patients with higher susceptibility to epileptic events. Based on our data, no formal recommendation can be made regarding the prophylactic use of anti-epileptic drugs. Nevertheless, the relative safety of new generation AEDs and the detrimental effect of postoperative seizure on outcome may justify its use in a selected patient population.

Burr hole craniostomy versus minicraniotomy in chronic subdural hematoma: a comparative cohort study

Background

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. In surgical management of CSDH, there is a lack of standardized guidelines concerning surgical techniques and a lack of consensus on which technique(s) are optimal. Neurosurgical centers have shown a wide variation in surgical techniques. The purpose of this study was to compare two different surgical techniques, one burr hole craniostomy with an active subgaleal drain (BHC) and minicraniotomy with a passive subdural drain (MC).

Methods

We conducted a multicenter retrospective cohort study at two neurosurgical centers in Sweden which included patients with unilateral CSDHs that received surgical treatment with either BHC or MC. The primary outcomes in comparison of the techniques were 30-day mortality, recurrence rate, and complications according to the Landriel Ibañez grading system for complications.

Results

A total of 1003 patients were included in this study. The BHC subgroup included 560 patients, and the MC subgroup included 443 patients. A 30-day mortality when comparing BHC (2.3%) and MC (2.7%) was similar (p = 0.701). Comparing recurrence rate for BHC (8.9%) and MC (10.8%) showed no significant difference (p = 0.336). We found that medical complications were significantly more common in the MC group (p = 0.001). Surgical complications (type IIb) was also associated with the MC group (n = 10, p = 0.003). Out of the 10 patients with type IIb complications in the MC group, 8 had postoperative acute subdural hematomas.

Conclusions

BHC was comparable to MC concerning 30-day mortality rate and recurrence rates. We did, however, find that MC was significantly associated with medical complications and serious surgical postoperative complications.

Drain type after burr-hole drainage of chronic subdural hematoma in geriatric patients: a subanalysis of the cSDH-Drain randomized controlled trial

OBJECTIVE

Chronic subdural hematoma (cSDH) occurs more frequently in elderly patients, while older patient age is associated with worse postoperative outcome following burr-hole drainage (BHD) of cSDH. The cSDH-Drain trial showed comparable recurrence rates after BHD and placement of either a subperiosteal drain (SPD) or subdural drain (SDD). Additionally, an SPD showed a significantly lower rate of infections as well as iatrogenic parenchymal injuries through drain misplacement. This post hoc analysis aims to compare recurrence rates and clinical outcomes following BHD of cSDH and the placement of SPDs or SDDs in elderly patients.

METHODS

The study included 104 patients (47.3%) 80 years of age and older from the 220 patients recruited in the preceding cSDH-Drain trial. SPDs and SDDs were compared with regard to recurrence rate, morbidity, mortality, and clinical outcome. A post hoc analysis using logistic regression, comparing the outcome measurements for patients < 80 and ≥ 80 years old in a univariate analysis and stratified for drain type, was further completed.

RESULTS

Patients ≥ 80 years of age treated with an SDD showed higher recurrence rates (12.8%) compared with those treated with an SPD (8.2%), without a significant difference (p = 0.46). Significantly higher drain misplacement rates were observed for patients older than 80 years and treated with an SDD compared with an SPD (0% vs 20%, p = 0.01). Comparing patients older than 80 years to younger patients, significantly higher overall mortality (15.4% vs 5.2%, p = 0.012), 30-day mortality (3.8% vs 0%, p = 0.033), and surgical mortality (2.9% vs 1.7%, p = 0.034) rates were observed. Clinical outcome at the 12-month follow-up was significantly worse for patients ≥ 80 years old, and logistic regression showed a significant association of age with outcome, while drain type had no association with outcome.

CONCLUSIONS

The initial findings of the cSDH-Drain trial and the findings of this subanalysis suggest that SPD may be warranted in elderly patients. As opposed to drain type, patient age (> 80 years) was significantly associated with worse outcome, as well as higher morbidity and mortality rates.

Drain type and technique for subdural insertion after burr hole evacuation of chronic subdural hematoma

Strengths and limitations of subdural versus subperiosteal drain location after burr hole evacuation of chronic subdural hematoma (CSDH) are currently debated. The safety of subdural placement of a drain has been questioned in a recent study by Soleman et al. from 2019, showing a misplacement rate of 17%, and these results have been further highlighted by the same authors, with a slightly lower misplacement rate of 15.8%, in the recent paper "When the drain hits the brain." The safety of subdural drainage for CSDH depends to a high degree on type of drain and surgical technique. In this technical note, we describe drain type and technique for drain placement which is standardized in Denmark.