A comparative study of treatment of chronic subdural hematoma — burr hole drainage versus continuous closed drainage

Seniority of Surgeon in Chronic Subdural Hematoma Recurrence: A Systematic Review and Meta-analysis

Chronic subdural hematoma (CSDH) is increasingly common, particularly in the older and multimorbid population. Surgical proficiency in management is required in the early years of U.K. neurosurgical training with most cases performed by nonconsultant-grade surgeons. The aim of this systematic review was to examine the effect of surgeon seniority on recurrence for patients with CSDH. Full-text articles comparing surgical treatment for CSDH with a "senior" (consultant/attending level) or "junior" (resident/registrar or similar) lead surgeon were identified. MEDLine and EMBASE databases were searched. The primary outcome of this study was recurrence. Secondary outcomes included postoperative complications and mortality rate. A random effects meta-analysis was performed. The risk of bias was assessed using the National Institute of Health risk of bias toolkit. Five studies were included in the final analysis (n = 941 total patients). Individually, no study identified a significant difference in recurrence rate and postoperative complications between senior and junior neurosurgeons. On meta-analysis, junior-led evacuations had lower recurrence rates on pooled univariable analysis (12.0% vs. 17.9% [odds ratio 0.48, 95% confidence interval 0.29-0.78, I2 = 0%]) (3 studies). Seniority of surgeon was not associated with increased rates of recurrence patients undergoing CSDH surgery. Complexity of operation may be a confounding factor in observed lower recurrence rates with more junior operators.

Subdural versus subgaleal drainage for chronic subdural hematomas: a post hoc analysis of the TOSCAN trial

OBJECTIVE

The use of subdural drains after surgical evacuation of chronic subdural hematoma (CSH) decreases the risk of recurrence and has become the standard of care. Halfway through the controlled, randomized TOSCAN (Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma) trial, the authors' institutional guidelines changed to recommend subgaleal instead of subdural drainage. The authors report a post hoc analysis on the influence of drain location in patients participating in the TOSCAN trial.

METHODS

The study involved 361 patients enrolled in the TOSCAN trial. The patients were stratified according to whether they received surgery before (cohort A) or after (cohort B) the change in institutional protocol. An intention-to-treat analysis was performed with surgery for recurrence as the primary endpoint. Secondary endpoints were outcome-based on modified Rankin Scale scores, seizures, infections, parenchymal brain injuries, and hematoma diameter.

RESULTS

Of the 361 patients included in the analysis, 214 were stratified into cohort A (subdural drainage recommended), while 147 were stratified into cohort B (subgaleal drainage recommended). There was a 31.78% rate of crossover from the subdural to the subgaleal drainage insertion site due to technical or anatomical difficulties. No differences in the rates of reoperation (21.5% [cohort A] vs 25.17% [cohort B], OR 0.81, 95% CI 0.50-1.34, p = 0.415), infections (0.47% [cohort A] vs 2.04% [cohort B], OR 0.23, 95% CI 0.02-2.19, p = 0.199), seizures (3.27% [cohort A] vs 2.72% [cohort B], OR 1.21, 95% CI 0.35-4.21, p = 0.765), or favorable outcomes (modified Rankin Scale score 0-3) at 1 and 6 months (91.26% [cohort A] vs 96.43% [cohort B], OR 0.39, 95% CI 0.14-1.07, p = 0.067; 89.90% [cohort A] vs 91.55% [cohort B], OR 0.82, 95% CI 0.39-1.73, p = 0.605) were noted between the two cohorts. Postoperatively, patients in cohort A had more frequent parenchymal brain tissue injuries (2.8% vs 0%, p = 0.041). Postoperative absolute and relative hematoma reduction was similar irrespective of the location of the drain.

CONCLUSIONS

Subgaleal rather than subdural placement of the drain did not increase the risk for reoperation for recurrence of CSHs, nor did it have a negative impact on clinical or radiological outcome. The intention to place a subdural drain was associated with a higher rate of parenchymal injuries.

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 (p = 0.87). In addition, no significant difference in time to recurrence was seen between groups (p = 0.74). 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.

External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults

BACKGROUND

Chronic subdural haematoma (CSDH) is one of the most common types of intracranial haematoma, and often occurs in older people. Burr-hole craniostomy, which is an evacuation through one or two burr holes drilled over the site of the haematoma, has been widely accepted as the most effective way to manage CSDH. Recurrences are a major problem and need reoperation, sometimes repeatedly.

OBJECTIVES

To assess the effects and safety of the use of external drains versus no drains after burr-hole evacuation for the treatment of CSDH in adults.

SEARCH METHODS

We ran our first search on 27 November 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE (OvidSP), Embase Classic+Embase (OvidSP), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S and CPSI-SSH), Chinese databases, and clinical trials registers, and screened reference lists. In compliance with the MECIR conduct standard 37, the Cochrane Injuries Group Information Specialist ran an update search within 12 months of publication (25 April 2016). We have screened these results but not incorporated the findings into the current review; as a result of the update search, one trial is awaiting classification.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared external subdural drains with no drains after burr-hole evacuation for the treatment of CSDH in adults.

DATA COLLECTION AND ANALYSIS

Two review authors identified potential articles from the literature search, extracted data independently using a data extraction form and assessed risk of bias using the Cochrane 'Risk of bias' tool. For dichotomous data, where statistical heterogeneity was low, we calculated summary risk ratios with 95% confidence intervals using a fixed-effect model.

MAIN RESULTS

Nine RCTs, including a total of 968 participants, reported outcomes specified by this review. Only one RCT reported the use of an adequate method of allocation concealment; this trial was a large, single-centre, high quality study and was adequately reported. All included trials reported a reduced recurrence of CSDH with external subdural drains. We found a significant reduction in the risk of recurrence with subdural drains (RR 0.45, 95% CI 0.32 to 0.61, I(2) = 38%; 9 studies, 968 participants; moderate-quality evidence). There was no strong evidence of any increase in complications (RR 1.15; 95% CI 0.77 to 1.72, I(2) = 0%; 7 studies, 710 participants; low-quality evidence), mortality (RR 0.78, 95% CI 0.45 to 1.33, I(2) = 22%; 5 studies, 539 participants; low-quality evidence), or poor functional outcome (which included deaths) (RR 0.68, 95% CI 0.44 to 1.05, I(2) = 31%; 5 studies, 490 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

There is some evidence that postoperative drainage is effective in reducing the symptomatic recurrence of CSDH. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Due to the low quality of the evidence for the secondary outcomes, the effect of drainage on the occurrence of surgical complications, mortality and poor functional outcome is uncertain. This uncertainty can be clarified with data from high-quality studies which may be conducted in the future. There is no strong evidence of any increase in complications when drains are used.

Surgical Treatments for Chronic Subdural Hematomas: A Comprehensive Systematic Review

BACKGROUND

Chronic subdural hematomas (CSDHs) are common neurosurgical conditions among elderly patients.

OBJECTIVE

To perform a detailed critical appraisal of all randomized controlled trials (RCTs) of surgical treatments for chronic subdural hematomas and to quantify their intervention effects.

METHODS

We performed a broad search for all RCTs with no language or date restrictions, asked the authors for missing data, and applied the Cochrane methods.

RESULTS

A total of 24 RCTs involved 1900 patients and 15 comparisons. All outcomes of practical interest were analyzed. Postoperative drainage after burr-hole evacuation reduced the rate of recurrence (risk ratio 0.48, 95% confidence interval 0.34-0.66, P < 0.00001) with no other clear benefits or complications.

CONCLUSIONS

This comprehensive, best evidence-based, quantitative, systematic review indicates that the use of a closed system drainage after burr-hole evacuation reduces the rate of recurrences but has no other significant differences. The findings also suggest that: (1) treatment with twist drills is equivalent to that with burr holes; (2) the postoperative bed header in the elevated position might reduce the length of hospital stay; (3) irrigation of the subdural space with thrombin solution in patients with high risk of recurrence might reduce this risk; and (4) treatment with twist drill followed by a closed system drainage during 48 hours, instead of 96 hours, might reduce general complication rates. Most of the trials suffered from unclear or high risks of bias and many involved small samples, precluding strong and definitive conclusions.

Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures

Object

In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH).

Methods

The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T2 (tau-squared), I2, and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis.

Results

Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage.

Conclusions

Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.