Subperiosteal Drainage versus Subdural Drainage in the management of Chronic Subdural Hematoma (A Comparative Study)

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.

Comparison of subperiosteal or subgaleal drainage and subdural drainage in patients with chronic subdural hematoma: A systematic review and meta-analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a relatively common disease, especially in the elderly, for which there is no clear standard of treatment available. The authors systematically evaluated the efficacy of various surgical procedures for the treatment of chronic subdural hematoma.

METHODS

Electronic databases of PubMed, EmBase, Web of Science, Medicine, and the Cochrane Library were searched systematically. Based on the PRISMA template, we finally selected and analyzed 13 eligible papers to evaluate the effect of different drainage methods on CSDH. The primary outcomes were recurrence and clinical outcomes. Secondary outcomes were mortality and postoperative complications and other parameters.

RESULTS

The meta-analysis included 3 randomized controlled trials and 10 retrospective studies (non-randomized controlled trials) involving 3619 patients. The pooled results showed no statistically significant difference between non-subdural drainage (NSD) and subdural drainage (SD) in mortality and complication rates (P > 0.05). Additionally, overall pooled results showed that the use of NSD (10.9%) has a lower recurrence rate than the use of SD (11.7%), but the results were not statistically significant (relative risk ratio [RR] = 0.98; 95% confidence interval [CI] = 0.70-1.45; I2 = 47%; P = .92). However, the difference between NSD and SD in postoperative bleeding rate reached statistical significance (RR = 2.39; 95% CI = 1.31-4.36; I2 = 0 %; P = .004). Subgroup analysis showed that SD was associated with similar recurrent CSDH (RR = 0.75; 95% CI = 0.52-1.09; I2 = 0%; P = .14), good recovery (RR = 0.98; 95% CI = 0.93-1.04; I2 = 0%; P = .50), and mortality (RR = 0.98; 95% CI = 0.37-2.57; I2 = 0%; P = .96), compared to NSD.

CONCLUSIONS

These results suggest that NSD and SD are equally effective in the treatment of patients with CSDH, with no difference in final clinical characteristics and radiologic outcomes. However, in patients with limited subdural space after evacuation of a hematoma, NSD may be the preferred strategy to avoid iatrogenic brain injury.

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.

A prospective randomized controlled trial of the effect of the number of burr hole on chronic subdural hematoma recurrence: An institutional experience

OBJECTIVE

The purpose of this study was to compare the effect of single burr hole (SBH) versus double burr hole (DBH) drainage on the recurrence rate of chronic subdural hematoma (CSDH).

METHOD

Forty-four patients undergoing burr hole craniostomy (BHC) between July 2022 and December 2022 were enrolled in a randomized clinical trial (RCT) comparing SBH to DBH surgeries. The primary endpoint of this study was the recurrence rate of CSDH. Radiological characteristics such as midline shift, thickness, volume, density, type of hematoma, brain atrophy and so on were secondary endpoints.

RESULTS

Forty-four patients participated in this study. Twenty-two hematomas underwent SBH craniostomy, and the other 22 had DBH craniostomy. The mean age in the SBH and DBH groups were 68.59 ± 7.94 and 69.54 ± 10.58, respectively. In each group, the proportion of males (SBH=16; DBH=15) was higher than that of females (SBH=6; DBH=7). The mean surgery time in the SBH group was significantly less than in the DBH group (p = 0.001). However, the two groups had no statistically significant difference in the CSDH recurrence rate (p = 0.312).

CONCLUSION

Our findings showed that SBH craniostomy is equally effective as DBH craniostomy at draining hematomas and does not increase the recurrence rate. Contrarily, the SBH craniostomy had a shorter surgical duration than the DBH craniostomy. As a result, we recommend SBH surgeries for all patients, with emphasis on the elderly and those with severe comorbidities, as well as in situations with few surgical facilities and a high patient admission rate.

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.

Risk factors for postoperative seizures in patients with chronic subdural haematomas

Postoperative seizures are a frequently occurring yet not well-understood complication in patients undergoing surgical treatment of chronic subdural haematomas (cSDHs). Therefore, we investigated surgical and non-surgical risk factors that are commonly considered causal in provoking epileptic seizures, paying special attention to the intracranial course of the subdural drain (SDD) and the configuration of the haematoma. Data of patients with a cSDH, that were treated at our neurosurgical department between 2008 and 2014 were analysed. Patients suffering from severe pre-existing conditions and those who have been treated conservatively were excluded. Epidemiologic data as well as relevant clinical data were collected. Pre- and postoperative CT scans were analysed regarding morpho- and volumetric parameters. In order to objectify the influence of the SDD, its intracranial course and localisation (entering angle as well as the angle between drain and brain surface) were measured. For statistical analysis, univariate and multiple logistic regression models as well as Fisher's exact test were used. Two hundred eleven consecutive patients have been included. Mean age was 75.6 years, and 69% were male. Nineteen (9%) patients suffered from postsurgical seizures. Membranes within the haematoma were present in 81.5%. Pre- to postoperative haematoma reduction was significant (mean of difference - 12.76 mm/ - 9.47 mm in coronal/axial CT planes, p = 0.001/ < 0.001). In 77.9%, SDD showed cortical contact with eloquent regions and had an unfavourable course in 30 cases (14.2%). Surgical complications consisted of cortical bleeding in 2.5%, fresh subdural haematoma in 33.5% and wound infections in 1.4% of patients. Neither in univariate nor in multiple regression analyses any of the following independent variates was significantly correlated with postsurgical seizures: pre-existing epilepsy, alcohol abuse, right-sided haematomas, localization and thickness of haematoma, presence of septations, SDD-localization and to-brain angle, subdural air, and electrolyte levels. Instead, in multiple regression analyses, we found the risk of postsurgical seizures to be significantly correlated and increased with left-sided cSDH treated via craniotomy (p = 0.03) and an unfavourable course of the SDD in left-sided cSDH (p = 0.033). Burr hole trepanation should be preferred over craniotomy and care must be taken when placing a SDD to avoid irritating cortical tissue. The configuration of the haematoma does not appear to affect the postoperative seizure rate.

Comparative study of subdural drain (SDD) versus sub periosteal drain (SPD) in treating patient with chronic subdural hematoma (CSDH)

Background:

Chronic subdural hematoma (CSDH) is common neurosurgical condition encountered in daily practice. Burr holes evacuation is standard treatment for symptomatic cases. Both subdural drain (SDD) and subperiosteal drain (SPD) have been reported to lower the recurrence rate when used in conjunction with burr holes. A randomized controlled trials were done to see if there were any differences in clinical and radiographic outcomes between the two types of drains.

Methods:

A total of 42 CSDH patients were enrolled and allocated to one of two groups: SDD (n = 21) or SPD (n = 21). Demographic data, perioperative imaging characteristics, clinical outcome, and recurrence rate were recorded for comparison.

Results:

In both groups, demographic characteristics such as sex ratio, mean age of patients, concomitant disease, and antithrombotic agent use were similar. At 6 months, 20 (95.2%) and 21 (100%) cases in the SDD and SPD groups, respectively, had a favorable outcome (mRS 0–3). Complete hematoma resolution at 6 months was achieved in 21 (100%) and 19 (90.5%) cases of the SDD and SPD groups, respectively. The amount of drain within 48 h was not difference between the two groups. None of the SDD recurred, but two of the SPD group did, necessitating reoperation, which had no effect on the final outcome.

Conclusion:

These findings indicate that the drain type (SDD or SPD) has no effect on the outcome. The surgeon’s preference determines which procedure is used. Except in symptomatic circumstances, routine postoperative imaging may not be required.

Comparative Study of Subgaleal and Subdural Closed Drain in Surgically Treated Cases of Chronic Subdural Hematoma

Background:

Chronic subdural hematoma (CSDH) is seen most common in geriatric patients, and trauma is the most important reason for CSDH. Operative treatment of CSDH in symptomatic patients is yet the gold standard of therapy because it allows decompression of the subdural space and aids improvement in neurological status. Burr-hole craniostomy is the most common accepted treatment for CSDH. There is still controversy regarding which type of drain placement is best in the outcome: subdural or subgaleal drain.

Aim:

The aim of the study was to compare the outcome of subgaleal versus subdural drain in surgically treated patients of CSDH.

Materials and Methods:

Patients were assigned by simple random sampling in two groups. The study was conducted from February 2016 to July 2017. A total of 70 patients were enrolled into the study and were divided in two groups (Group 1 – Subgaleal drain; Group 2 – Subdural drain). Statistical analysis was done using Chi-square and t-test. Outcome was assessed at the end of hospital stay by modified Rankin scale. Postoperative computed tomography scan was done after 24 h of surgery.

Results:

This study concluded that both types of drains are equally effective for the treatment of CSDH. There is a statistically significant difference in the occurrence of seizure in both the groups as there was no seizure in subgaleal drain group compared to 5 (14.3%) patients who had seizures postoperatively in subdural drain group (P = 0.020). There was insignificant difference with respect to preoperative Glasgow Coma Scale/sex/preoperative hematoma volume/postoperative hematoma volume/preoperative midline shift.

Conclusion:

Subgaleal drain is safe and technically easy, as subgaleal drain has no direct contact with brain parenchyma, thus less chances of brain laceration, intracerebral hematoma formation, and seizures.

Drains result in greater reduction of subdural width and midline shift in burr hole evacuation of chronic subdural haematoma

BACKGROUND

Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome.

METHODS

A multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression.

RESULTS

Three hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus 'no drain' groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome.

CONCLUSIONS

The use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use.

Type of Drain in Chronic Subdural Hematoma-A Systematic Review and Meta-Analysis

Background: Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases, while burr-hole drainage is the most frequently used surgical treatment. Strong evidence exists that subdural drain (SDD) placement reduces recurrence rates. However, the insertion of a subperiosteal drain (SPD) was shown to lead to similar recurrence rates and less complications than SDD. The aim of this study is to provide a systematic review of the literature and conduct a meta-analysis of studies comparing SPD with SDD after burr-hole drainage of cSDH.

Methods: Pubmed and Embase databases were searched using a systematic search strategy to identify studies on drain location up to December 2019. Two independent researchers assessed the studies for inclusion and quality. Primary outcome measure was recurrence, while secondary outcome measures were drain misplacement, morbidity, mortality, and clinical outcome. Besides randomized controlled trials (RCT), we included non-randomized prospective cohort studies, as well as retrospective cohort studies. A fixed effects model was used if low heterogeneity (I² < 50%) was present, otherwise a random effects model was used.

Results: Following removal of duplicates, we screened 1109 articles of which 10 articles were included in our qualitative and quantitative analyses. One study was an RCT, three were non-randomized prospective cohort studies, and the remaining articles were retrospective cohort studies or subgroup analysis. In these 10 articles, 1,553 patients were treated with SPD and 1782 patients with SDD. Comparing the recurrence rate of cSDH a significant difference was found between SPD and SDD insertion (11.9 and 12.3%; RR 0.8, 95% CI 0.67–0.97, I² = 0%, z = −2.27, p = 0.02). SPD had significantly lower rates of drain misplacement and parenchymal injuries (1.2 and 7.8%; RR 0.17, 95% CI 0.07–0.42, I² = 0%, z = −3.4, p = 0.0001), as well as morbidity (6.4 and 8.2%; RR 0.65, 95% CI 0.5–0.84, I² = 44.5%, z = −3.32, p =0.0009). Mortality rates (5.0 and 4.6%; RR 0.83, 95% CI 0.6–1.14, I² = 0%, z = −1.2, p = 0.25) and favorable clinical outcome (89.6 and 88.9%; RR 1.1, 95% CI 0.89–1.24, I² = 54.2%, t = 0.98, p = 0.40) were comparable in both groups.

Conclusion: The insertion of SPD after burr-hole drainage of cSDH showed lower rates of recurrence, drain misplacements and parenchymal injuries, as well as overall morbidity, while clinical outcome and mortality were comparable to SDD. Therefore, the insertion of SPD after surgical drainage of cSDH should be encouraged.

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.

A closed system irrigation & drainage technique for surgical evacuation of chronic subdural haematomas

Background: Chronic subdural haematoma (CSDH), is a common neurosurgical disorder that is associated with morbidity and mortality affecting the ageing population. The aim is to present the treatment experience of CSDH patients treated with a technique that combines the classical single burr-hole irrigation and the continuous closed system drainage: The closed system irrigation & drainage (CSID) technique. Methods: The cases undergoing CSDH evacuation with the CSID method were captured over a 4-year period at a tertiary neurosurgical centre. The authors describe the performance of this methods with respect to post-operative clinical and radiological features, including recurrence rates, complications, and length of stay. Results: A total of 36 cases undergoing 42 CSID procedures (30 unilateral and 6 bilateral CSDHs) were performed, in cases ranging between 55-95 years old (median age 79 years). The rate of recurrence or significant ruminant blood in the subdural space on post-operative imaging was 11% (n=4). No cases of pneumocephalus were observed in this series (n=0). The mean (SD) skin-to-skin time for this procedure was 13.4 (4.4) minutes, with a mean (SD) length of stay of 4 (1.9) days. Conclusion: We conclude that the one burr-hole closed system irrigation and drainage technique with a sub-periosteal drain seems to be a simple, effective and safe procedure for treatment of CSDH. It's well tolerated under local anaesthesia for patients with high co-morbidities and these preliminary results indicated it may potentially be a better option for treatment of CSDH with a lower rate of post-operative complications.