Is the recurrence rate of chronic subdural hematomas dependent on the duration of drainage?

Is a drainage time of less than 24 h sufficient after chronic subdural hematoma evacuation?

BACKGROUND

It is well established that the use of a postoperative drain after chronic subdural hematoma surgery reduces recurrence rates, and it is common to use a postoperative drain for longer than 24 h. It is unclear whether this is superior to a shorter drainage time of less than 24 h. Our aim was to compare a postoperative drainage longer or shorter than 24 h after chronic subdural hematoma evacuation.

MATERIALS AND METHODS

In this retrospective single centre study, 207 adult patients undergoing chronic subdural hematoma evacuation with a postoperative drainage longer (LDT-group) or shorter (SDT-group) than 24 h were compared regarding recurrence, mortality within 6 months and complications requiring hospital admission within 30 days. Length of hospital stay was also recorded. An active subgaleal drain was used. In addition to the retrospective cohort, we also studied the total volume drained per hour after cSDH surgery in a prospective cohort of 10 patients.

RESULTS

Recurrence occurred in 12/96 (12.5%) in the LDT-group and in 13/111 (11.7%) patients in the SDT-group (p = 0.15). There was no significant difference between groups regarding recurrence, complications or mortality. The prospective cohort showed that most of the drainage occurred within the first hours after surgery.

CONCLUSION

Our data show that a postoperative drainage duration of less than 24 h does not lead to an increase in recurrence, complications or mortality compared to a drainage time of more than 24 h. A shorter drainage duration (< 24 h) after cSDH surgery facilitated earlier mobilisation and shorter hospital stay.

Comparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence

BACKGROUND

 Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage, especially among the elderly, with a recurrence rate as high as 33%. Little is known about the best type of drainage system and its relationship with recurrence. In this study, we compare the use of two drainage systems on the recurrence rate of CSDH.

METHODS

 We retrospectively analyzed the charts of 172 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: group A (n = 123) received a pediatric size nasogastric tube [NGT]), whereas group B (n = 49) had a drain commonly used for external ventricular drainage (EVD). Various demographic and radiologic data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months.

RESULTS

 In all, 212 cases of CSDH were treated in 172 patients. The majority of patients were male (78%) and had a history of previous head trauma (73%). Seventeen cases had recurrence, 11 in group A and 6 in group B. The use of antiplatelet and anticoagulation agents was associated with recurrence (p = 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence (odds ratio [OR] = 1.42; 95% confidence interval [CI]: 0.49-4.08; p = 0.573).

CONCLUSION

 CSDH is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to reduce the incidence of recurrence, little is known about the best type of drain to use. Our analysis showed no difference in the recurrence rate between using the pediatric size NGT and the EVD catheter post-TDC.

The Role of Active or Passive Drainage after Evacuation of Chronic Subdural Hematoma: An Analysis of Two Randomized Controlled Trials (cSDH-Drain-Trial and TOSCAN Trial)

The evacuation of a chronic subdural hematoma (cSDH) is one of the most common procedures in neurosurgery. The aim of this study was to assess the influence of drainage suction in the surgical treatment of cSDH on the recurrence rate. Post hoc analysis was conducted on two randomized controlled trials (cSDH-Drain-Trial and TOSCAN trial) stratifying a total of 581 patients into active or passive drain type. Of the 581 patients, 359 (61.8%) and 220 (37.9%) were stratified into the active and passive drainage groups, respectively. The reoperation rate following postoperative recurrence was 23.1% and 14.1% in the active and passive drainage groups, respectively (p < 0.011). After propensity score matching, the differences in recurrence rate remained significant (26.6% versus 15.6%, p = 0.012). However, the functional outcome (mRS) at 6−12 months did not differ significantly (median [IQR]) between the 2 groups (passive drainage group 0.00 [0.00, 2.00], active drainage group 1.00 [0.00, 2.00], p = 0.431). Mortality was comparable between the groups (passive drainage group 12 (5.5%), active drainage group 20 (5.6%), p = 0.968). In the univariate analysis, active drainage, short (<48 h) duration of drainage, and early (<48 h) postoperative mobilization were significantly associated with a higher recurrence rate. However, the multivariate logistic regression model could not confirm that any of these parameters were significantly associated with recurrence. Our post hoc analysis proposes that using a passive instead of an active drain might be associated with a reduced recurrence rate after evacuation of a cSDH. We suggest gathering further evidence by means of a randomized controlled trial.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.

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.

Management of chronic subdural hematoma with the subdural evacuating port system: Systematic review and meta-analysis

The subdural evacuating port system (SEPS) is a minimally invasive option for treating chronic subdural hematoma (cSDH). Individual case series have shown it to be safe and effective, but outcomes have not been systematically reviewed. We sought to review the literature in order to determine the safety and efficacy of SEPS as a first line treatment for cSDH. A comprehensive literature search for outcomes following SEPS placement as a primary treatment for cSDH was performed. The primary outcome was treatment success, which was defined as a composite of improvement in presenting symptoms and no need for further treatment in the operating room. Additional outcomes included discharge disposition, length of stay (LOS), hematoma recurrence, and complications. A total of 12 studies comprising 953 patients who underwent SEPS placement met the inclusion criteria. The pooled rate of a successful outcome was 0.79 (95% CI 0.75-0.83). Frequency of delayed hematoma recurrence was 0.15 (95% CI 0.10-0.21). The pooled inpatient mortality rate was 0.02 (95% CI 0.01-0.03). Complications rates included 0.02 (95% CI 0.00-0.03) for any acute hemorrhage, 0.01 (95% CI 0.00-0.01) for acute hemorrhage requiring surgery, and 0.02 (95% CI 0.01-0.03) for seizure. SEPS placement is associated with a success rate of 79% and very low rates of acute hemorrhage and seizure. This data supports its use as a first-line management strategy, although prospective randomized studies are needed.

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.

Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study

Background

Drain insertion following chronic subdural hematoma (CSDH) evacuation improves patient outcomes.

Objective

To examine whether this is influenced by variation in drain location, positioning or duration of placement.

Methods

We performed a subgroup analysis of a previously reported multicenter, prospective cohort study of CSDH patients performed between May 2013 and January 2014. Data were analyzed relating drain location (subdural or subgaleal), position (through a frontal or parietal burr hole), and duration of insertion, to outcomes in patients aged >16 yr undergoing burr-hole drainage of primary CSDH. Primary outcomes comprised modified Rankin scale (mRS) at discharge and symptomatic recurrence requiring redrainage within 60 d.

Results

A total of 577 patients were analyzed. The recurrence rate of 6.7% (12/160) in the frontal subdural drain group was comparable to 8.8% (30/343) in the parietal subdural drain group. Only 44/577 (7.6%) patients underwent subgaleal drain insertion. Recurrence rates were comparable between subdural (7.7%; 41/533) and subgaleal (9.1%; 4/44) groups (P = .95). We found no significant differences in discharge mRS between these groups. Recurrence rates were comparable between patients with postoperative drainage for 1 or 2 d, 6.4% and 8.4%, respectively (P = .44). There was no significant difference in mRS scores between these 2 groups (P = .56).

CONCLUSION

Drain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification.

Recurrence Rate of Chronic Subdural Hematoma after Evacuating It by Two Large Burr Holes, Irrigation, and Subgaleal Low-Pressure Suction Drainage

Background:

There are no current standard operative steps for chronic subdural hematoma (CSDH). The aim of this study was to detect the recurrence rate after drainage of a unilateral diffuse CSDH by combining certain operative steps.

Materials and Methods:

This is a descriptive, retrospective cohort study that included 47 consecutive adult patients who underwent evacuation of a unilateral diffuse CSDH by two large burr holes (≥2 cm in diameter) and irrigation of the subdural space by warm saline, followed by placement of a subgaleal Redivac drain under low-pressure suction in our university hospital from August 2012 to August 2016. There were 29 men and 18 women with a mean age of 69.1 years.

Results:

All the operations were uneventful. All the patients had adequate drainage of their subdural hematomas, and all patients were discharged alert and oriented. No incidence of recurrence within 12 months after surgery.

Conclusion:

This study demonstrated that surgical management of a unilateral diffuse CSDH in adult patients by two large burr holes, irrigation, and a subgaleal Redivac low-pressure suction drainage was effective and associated with no recurrence.

The depth of catheter in chronic subdural haematoma: does it matter?

Objective: To investigate the appropriate depth of drainage catheter in the patients with chronic subdural haematoma (CSDH). Methods: We retrospectively analysed the data of 190 patients with CSDH undergoing single parietal burr-hole evacuation and drainage. Results: According to the depth of catheter (DC), 190 patients were divided into three groups: shallow group (DC <4.3 cm), middle group (DC 4.3 ~ 5.4 cm) and deep group (DC > 5.4 cm). During postdischarge 6 months, two, six and nine patients had recurrences in shallow, middle and deep groups, respectively. The recurrence rate in shallow or middle group was significantly lower than that in deep group. No significant difference in preoperative haematoma volume (PHV) was observed in three groups. While the residual subdural space (RSS) in shallow group was significantly smaller than those in the other two groups. The duration of drainage in shallow, middle and deep groups increased successively, and the differences were statistically significant. The total drainage volume (TDV) in shallow group showed no significant difference when compared with the other two groups. Conclusion: The depth of catheter may affect the outcome of CSDH. Inserting drainage catheter shallowly might be a preferred choice in patients with CSDH undergoing burr-hole evacuation and drainage.

Subdural Tension on the Brain in Patients with Chronic Subdural Hematoma Is Related to Hemiparesis but Not to Headache or Recurrence

BACKGROUND

Hemiparesis is a major symptom of chronic subdural hematoma (CSDH). Its severity does not always correlate with hematoma size. The authors analyzed hematoma thickness, pressure, and tension to clarify the mechanism of hemiparesis in CSDH patients.

METHODS

A burr-hole surgery was performed on 124 CSDHs in 102 patients. Hematoma thickness and midline shift were measured by computed tomography, and hematoma pressure was measured in surgery. According to Laplace law, tension was calculated as follows: (half the hematoma thickness × hematoma pressure)/2. Student t test and Pearson correlation coefficient (r) were applied in statistical analysis of findings.

RESULTS

Motor weakness was identified in 76.5% of our cases. Tension was strongly related to hemiparesis (r = -0.747, P < 0.01), whereas hematoma thickness (r = -0.458, P < 0.01) and pressure (r = -0.596, P < 0.01) were moderately correlated. Mean age of 14 patients (13.7%) with headache was much younger than those without headache (P < 0.01). Stronger midline shift (P < 0.01) and greater ratio of midline shift to hematoma thickness (P < 0.01) were statistically correlated with headache. Recurrence was recognized in 8 patients (7.8%), and stronger midline shift (P < 0.05) and greater ratio of midline shift to hematoma thickness (P < 0.05) were statistically associated with recurrence.

CONCLUSIONS

Tension is the most influencing factor to hemiparesis in CSDH patients. This study also elucidates the mechanism for quick recovery from hemiparesis after surgery in that tension on the motor cortex is decreased immediately by drainage.