Indications and surgical results of twist-drill craniostomy at the pre-coronal point for symptomatic chronic subdural hematoma patients

Butterfly needle tap and suction (BTS) technique: a treatment for recurrent chronic subdural hematoma after burr hole craniostomy

BACKGROUND

In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle.

METHODS

This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications.

RESULTS

Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0 ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4 ml in the BTS-alone group and 49.4 ± 12.9 ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein.

CONCLUSIONS

The BTS technique is an effective alternative to reoperation with BHC.

Fibrinolytic-Facilitated Chronic Subdural Hematoma Drainage-A Systematic Review

BACKGROUND

The current treatment options for chronic subdural hematoma (CSDH) include burr hole drainage, twist drill drainage, and craniotomy with or without postoperative catheter drainage. Although generally effective, these treatments have continued to be complicated by recurrence, especially in partially hemolyzed or septated hematomas. Recently, interest in the use of fibrinolytic agents as an adjunct to surgical treatment to address this limitation has been increasing. We conducted a systematic review, focusing on the efficacy and safety profile of fibrinolytic agents and compared the different fibrinolytic agents.

METHODS

The PubMed, EMBASE, CINAHL Plus, and Cochrane Library databases were searched for trials relevant to fibrinolytic administration in the treatment of CSDH. The findings are reported in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The data from 1702 subjects from 6 retrospective observational studies were qualitatively analyzed. In addition, we included 11 case series and reports for discussion.

RESULTS

For 1449 patients, the use of urokinase or tissue plasminogen activator improved hematoma drainage and shortened the hospital stay (7.04 days), with an overall hematoma recurrence rate of 1.59%. The incidence of infection, seizure, and intracranial bleeding was 3.18%, 0.80%, and 0.41%, respectively, which compared favorably with previously reported findings for surgical drainage without the use of fibrinolytic agents.

CONCLUSIONS

The routine use of intrathecal urokinase and tissue plasminogen activator could be a new direction in the management of CSDH. Conclusive clinical evidence is lacking, however, and further prospective controlled studies are warranted to confirm the benefit and safety of this treatment strategy and to identify the optimal agent and dosing regimen.

Bedside Percutaneous Twist Drill Craniostomy of Chronic Subdural Hematoma-A Single-Center Study

Background  Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. Objectives  This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC). Patients and Methods  A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Statistical Analysis  Statistical analysis is done using Epi Info software. Results  The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD. Conclusions  CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

Modified bedside twist drill craniostomy for evacuation of chronic subdural haematoma

Introduction

Standard craniotomy (SC) and burr hole craniostomy (BHC) are regarded as the standard approaches to chronic subdural haematoma (CSDH). Bedside twist drill craniostomy (TDC), performed at the patient’s bedside, was introduced as an alternative to the standard methods. However, clinical and radiological features of patients treated with TDC and BHC/SC have not been compared.

Aim

To demonstrate the specific features of CSDH that affect the surgeons’ preferences when selecting patients for TDC.

Material and methods

A retrospective analysis of 32 patients treated due to CSDH in the year 2017 at a single institution was performed. Baseline radiological characteristics, clinical status at admission, complication rate and clinical outcomes were compared between BHC/SC and TDC.

Results

Of the 32 patients, 5 (15.6%) were treated using TDC and 27 (84.4%) by SC or BHC. The duration of the TDC procedure was significantly shorter than the time of standard therapies (p < 0.01). There were no differences between TDC and BHC/SC in terms of baseline clinical characteristics, including age, gender, head trauma history, diabetes, hypertension, antiplatelet drug use, clinical manifestation and the Glasgow Coma Scale score (all p > 0.05). Patients treated with TDC had a significantly thicker haematoma (TDC vs. BHC/SC: mean 25.3 mm vs. 14.6 mm) (p < 0.01) and demonstrated a smaller midline shift (TDC vs. BHC/SC: mean 0.5 mm vs. 4.0 mm) (p = 0.01) compared to those treated with BHC/SC.

Conclusions

Twist drill craniostomy is a more effective method for CSDH evacuation compared to SC and BHC. This procedure is considered as the first line treatment for patients with a thicker and non-septated haematoma, and with a smaller midline shift.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma

Background

Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. On accounting its risk-to-benefit ratio, there was always controversy regarding the management of the CSDH as to which procedure is superior.

Aims

The aim is to compare the clinical and radiological outcomes in patients of CSDH who have undergone single burr-hole craniostomy (BHC) versus twist-drill craniostomy (TDC).

Patients and Methods

A retrospective study was conducted in patients admitted with CSDH who had undergone single BHC or TDC between January 2014 and December 2016. Patients between 18 and 90 years of age were selected. Patients with CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, and mixed density were selected. CT scan findings of CSDH with hyperdense gravity-dependent fluid level were also selected. Patients with CT evidence of multiple septations were excluded from the study. Recurrent CSDH, bilateral CSDH, and CSDH with secondary acute bleed were also excluded. Diagnosis was done using noncontrast CT scan. The maximum thickness of the CSDH was measured in the axial film of CT scan. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline in axial CT film. The mass effect was determined by the effacement of the sulci, sylvian fissure obscuration, or compression of lateral ventricles. The decrease in the signs and symptoms in postoperative period was considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of the MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Patients with significant residue underwent reoperation.

Results

There were 63 patients in BHC group and 46 patients in TDC group. The mean age in BHC and TDC groups was 61.39 ± 13.21 standard deviation (SD) and 73.36 ± 10.82 SD, respectively. There were 48 (76.19%) male and 15 (23.81%) female in BHC group. There were 32 (69.57%) male and 14 (30.43%) female in TDC group. In BHC group, 41.27% were on the right side and 58.73% on the left side. In TDC group, 50% were on the right side and 50% on the left side. In BHC group, 82.54% were in the frontotemporoparietal region, 9.52% in the frontoparietal region, 6.35% in the temporoparietal region and 1.58% in the parietooccipital region. In TDC group, 86.95% were in the frontotemporoparietal region, 8.69% in the frontoparietal region, 2.17% in the temporoparietal region, and 2.17% in the parietooccipital region. There was no significant difference in duration of symptoms and history of trauma in both the groups. The symptoms of the patients in BHC versus TDC include weakness of the limbs (44.44% vs. 73.91%), headache (50.79% vs. 32.60%), altered sensorium or decreased memory (44.44% vs. 54.4%), vomiting (19.04% vs. 6.52%), speech abnormalities (15.87% vs. 19.56%), urinary incontinence (25.39% vs. 15.21%), seizure (1.58% vs. 4.34%), and diplopia (4.76% vs. 0%). The mean preoperative Glasgow Coma Scale (GCS) score in BHC versus TDC was 13.44 ± 2.23 SD versus 12.47 ± 2.95 SD limb weakness was noted in 52.38% BHC group and 82.60% TDC group. There was significantly decreased GCS score in TDC group. The number of the patients with limb weakness on affected side was significantly more in TDC group. The mean maximum thickness of the CSDH (in millimeter) in axial CT scan was 17.22 ± 4.29 SD in BHC group and 22.21 ± 4.52 SD in TDC group. The number of patients with MLS was 59 (93.65%) in BHC group and 45 (97.82%) in TDC group. There was significant difference in thickness of CSDH in both the groups. However, there was no significant difference in MLS in both the groups. There was no significant difference in prothrombin time, International Normalized Ratio, and activated partial thromboplastin time values of both the groups. There was significant difference in platelet counts of both the groups. The mean duration of procedure (in minutes) in BHC versus TDC was 79.20 ± 26.76 SD versus 27.47 ± 4.80 SD. The duration of procedure was significantly more in BHC compared to TDC. In postoperative assessment, there was no significant difference in the GCS score, power improvement, power deterioration, clinical improvement, and improvement in CT scans of both the groups. Postoperative CSDH residue requiring reoperation was significantly more in TDC group against the BHC group (13.04% vs. 1.58%). There was no significant difference in the development of acute subdural hematoma (SDH) (4.76% vs. 8.6%), reoperation rate (6.35% vs. 17.39%), complications (9.52% vs. 15.21%), and death (4.76% vs. 10.87%) in BHC group vs. TDC group. There was no significant difference in the period of hospital stay (days) in BHC (8.90 ± 5.89 SD) and TDC groups (7 ± 4.24 SD).

Conclusion

The duration of procedure was significantly more in BHC than in TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH.

Chronic Subdural Hematoma Associated with Fahr Syndrome: A Clinical Association or Just a Simple Coincidence?

The Fahr syndrome (FS) is a rare degenerative neurological disorder (its prevalence is <0.5%). FS is distinguished by the presence of abnormal bilateral intracranial calcifications with a predilection for the basal ganglia, also presented by movement disorders such as parkinsonism, paresis, and speech disorders. Chronic subdural hematoma (CSH), which is typically the result of mild head trauma, is a regularly encountered condition in elderly. A 63-year-old man has referred to our clinic from another hospital with a history of mild head trauma approximately a month ago. At the time of admission, the patient's Glasgow Coma Scale point was 15 points. In the history, there was only mild ataxia and right-sided hemiparesis. The laboratory examination revealed no electrolytes level abnormalities and normal endocrinal test examinations. Computed tomography revealed bilateral calcifications of basal ganglia, dentate nuclei which were misinterpreted as intracerebral contusion; with CSH of left temporal and parietal region. The hematoma was evacuated by burr-hole drainage. The patient was discharged 5 days after the surgery. The pathophysiology of FS is still unrevealed. There are some suggestions such as secondary to local disturbance of blood-brain barrier or a calcium neuronal metabolism disorder. However, on the other hand, local blood-brain barrier disturbance would also take part in CSH pathology. We hypostasized that patients with the history of FS, who had mild head traumas, might prone to subdural collections. On the other hand, FS and CSH coexistence is very unusual. Neurosurgeons might keep in mind FS when bilateral calcifications are seen in a patient.

Twist-Drill or Burr Hole Craniostomy for Draining Chronic Subdural Hematomas: How to Choose It for Chronic Subdural Hematoma Drainage

Objective

Although twist-drill craniostomy (TDC) has a number of procedural advantages and an equivalent outcome compared to burr hole craniostomy (BHC) for the treatment of chronic subdural hematomas (CSDHs), the latter technique remains the preferred method. We analyzed symptomatic CSDHs in whom TDC at the pre-coronal suture entry point (PCSEP) was the primary method for hematoma drainage and BHC on the parietal was the secondary option.

Methods

CSDHs in 86 consecutive patients were included. TDC at the PCSEP, which is 1 cm anterior to coronal suture at the level of the superior temporal line, was the primary operational technique when the hematoma thickness was suitable, and BHC was performed via the parietal when TDC was unreasonable or failed. The clinical feasibility and outcomes of these approaches were analyzed.

Results

Of the 86 patients, 68 (79.1%) were treated by TDC, and 18 (20.9%) by BHC. All patients showed improvements in their symptoms after hematoma drainage. Neither morbidity nor mortality was associated with either technique, and there were no differences in drainage days between the groups. Ten patients had bilateral hematomas and were treated using TDC. Two patients were not sufficiently treated by TDC and, as a result, BHC was applied. Only six hematomas (7% of 86 hematomas) exhibited insufficient thickness on the computed tomography to perform TDC.

Conclusion

When the hematoma was thick enough, a majority of the CSDHs were drained using TDC at the PCSEP as the first procedure, which was especially useful for bilateral hematomas and in elderly patients.

Comparison of the Indications and Treatment Results of Burr-Hole Drainage at the Maximal Thickness Area versus Twist-Drill Craniostomy at the Pre-Coronal Point for the Evacuation of Symptomatic Chronic Subdural Hematomas

Objective

To analyze the clinical data and surgical results from symptomatic chronic subdural hematoma (CSDH) patients who underwent burr-hole drainage (BHD) at the maximal thickness area and twist-drill craniostomy (TDC) at the precoronal point.

Methods

We analyzed data from 65 symptomatic CSDH patients who underwent TDC at the pre-coronal point or BHD at the maximal thickness area. For TDC, we defined the pre-coronal point to be 1 cm anterior to the coronal suture at the level of the superior temporal line. TDC was performed in patients with CSDH that extended beyond the coronal suture, as confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed and analyzed.

Results

Of the 65 CSDH patients, 13/17 (76.4%) with BHD and 42/48 (87.5%) with TDC showed improved clinical performance and radiological findings after surgery. Catheter failure was seen in 1/48 (2.4%) cases of TDC. Five patients (29.4%) in the BHD group and four patients (8.33%) in the TDC group underwent reoperations due to remaining hematomas, and they improved with a second operation, BHD or TDC.

Conclusion

Both BHD at the maximal thickness area and TDC at the pre-coronal point are safe and effective drainage methods for symptomatic CSDHs with reasonable indications.

Chronic subdural haematoma: modern management and emerging therapies

Chronic subdural haematoma (CSDH) is one of the most common neurological disorders, and is especially prevalent among elderly individuals. Surgical evacuation is the mainstay of management for symptomatic patients or haematomas exerting significant mass effect. Although burr hole craniostomy is the most widely practised technique worldwide, approximately 10-20% of surgically treated patients experience postoperative recurrence necessitating reoperation. Given the increasing incidence of CSDH in a growing elderly population, a need exists for refined techniques that combine a minimally invasive approach with clinical efficacy and cost-effectiveness. In addition, nonsurgical treatment modalities, such as steroids, are attracting considerable interest, as they have the potential to reduce postoperative recurrence or even replace the need for surgery in selected patients. This Review provides an overview of the contemporary management of CSDH and presents considerations regarding future approaches that could further optimize patient care and outcomes.