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Li S, Farsakh A, Toomey F, Tan D, Tran V, Castle-Kirszbaum M, Moore J, Lai L, Kam J. Subdural Versus Subgaleal Drain Placement After Minicraniotomy for Chronic Subdural Hematoma. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01200. [PMID: 38888301 DOI: 10.1227/ons.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/18/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Surgical evacuation with placement of a postoperative drain is the standard treatment for symptomatic chronic subdural hematoma (cSDH). Subdural and subgaleal drains are equally effective after burrhole craniostomy, but the optimal location of the drain after craniotomy is not clear. We sought to compare the clinical and radiological outcomes of subdural and subgaleal drain placement in patients undergoing minicraniotomy for cSDH. METHODS A retrospective review of 137 consecutive patients undergoing minicraniotomy for cSDH at a single institution was performed. Cases were stratified by location of postoperative drain. The primary outcome was change in functional status (modified Rankin Score, mRS) at 3 months from preoperative baseline. RESULTS Among the patient cohort, 24.6% received subgaleal drain placement. After a median follow-up of 105 days, 79.4% (27/34) in the subgaleal group and 57.3% (59/103) in the subdural group (P = .02) had been discharged home. Worse premorbid mRS (P = .002), subdural drain location (P = .004), and decreased consciousness at presentation (Glasgow Coma Scale<15) (P < .002) were independent predictors of a discharge destination other than home. At the 3-month follow-up, the subgaleal group exhibited a mean improvement of 0.77 ± 1.2 points, while the subdural group had a deterioration of 0.14 ± 0.8 points (P < .01). Subgaleal drain location (P < .0001), better preoperative Glasgow Coma Scale (P = .01), and worse premorbid mRS (P = .0003) were independent predictors of improved mRS at 3 months. Recurrence requiring repeat surgery were more common in the subdural (13.6% (14/103) than the subgaleal 2.9% (1/34) group, P = .12), although the absolute incidence rates remained low. CONCLUSION In patients undergoing minicraniotomy for cSDH, subgaleal drains are associated with shorter hospitalization, greater chance of discharge home, and better functional outcomes than subdural drains.
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Affiliation(s)
- Sandra Li
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ameen Farsakh
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Fidel Toomey
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Darius Tan
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Vu Tran
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Mendel Castle-Kirszbaum
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Justin Moore
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Leon Lai
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Jeremy Kam
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne Health, Melbourne, Victoria, Australia
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Sharma M, Yadav N, Ratre S, Bajaj J, Hadaoo K, Patidar J, Sinha M, Parihar V, Swamy NM, Yadav YR. Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor. World Neurosurg 2024:S1878-8750(24)00900-8. [PMID: 38815922 DOI: 10.1016/j.wneu.2024.05.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation. METHODS A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed. RESULTS The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality. CONCLUSIONS Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.
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Affiliation(s)
- Mukesh Sharma
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Nishtha Yadav
- Department of Neuroradiology, NSCB Medical College, Jabalpur, India
| | - Shailendra Ratre
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Ketan Hadaoo
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Jayant Patidar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Mallika Sinha
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Narayan M Swamy
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India
| | - Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, India.
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Sirinoglu D, Sarigul B, Aydin MV. Mini-Perforated Craniotomy with Subperiosteal Drain for Evacuation of Chronic Subdural Hematoma: A New Technique and Clinical Study. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1758658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Purpose Chronic subdural hematoma (cSDH) is a frequent disease of the elderly with favorable outcomes. The main choice of treatment is surgery. Along with many surgical techniques described for evacuation of cSDH, we are presenting the preliminary outcomes of a novel surgical method, mini-perforated craniotomy with a subperiosteal drain.
Materials and Methods Patients in whom cSDH with thickness of >10 mm was observed in computed tomography (CT) scans with parenchymal compression and/or midline shift were included in this study. Age, sex, complaint, neurological status, and medical history were recorded along with CT findings. Mini-perforated craniotomy was performed on all patients. A subperiosteal drain was used. The postoperative follow-up period was 3 months.
Results Ten cSDH patients who were admitted to Prof. Dr. Cemil Tascioglu City Hospital between December 2020 and May 2021 were included in this study. The mean age was 64.3 ± 6.272, and the most common admission complaint was a headache. Postoperatively, one patient showed acute rebleeding after the operation due to dual anticoagulant therapy. Besides, in 3 months follow-up, rebleeding, subdural or epidural effusion, wound infection, or cosmetic problems were not observed.
Conclusion Mini-perforated craniotomy with a subperiosteal drain may be an alternative method for evacuation of cSDH with low complication rates especially when the hematoma is suspected to be septated.
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Affiliation(s)
- Deniz Sirinoglu
- Department of Neurosurgery, Prof. Dr. Cemil Tascioglu City Hospital, İstanbul, Turkey
| | - Buse Sarigul
- Department of Neurosurgery, Tuzla Public Hospital, İstanbul, Turkey
| | - Mehmet Volkan Aydin
- Department of Neurosurgery, Prof. Dr. Cemil Tascioglu City Hospital, İstanbul, Turkey
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4
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Bajaj J, Yadav YR. Mini-Perforated Craniotomy with Subperiosteal Drainage. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1758632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Jitin Bajaj
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yad Ram Yadav
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Solou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, Savvanis G, Stavrinou LC. Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics (Basel) 2022; 12:2060. [PMID: 36140462 PMCID: PMC9498240 DOI: 10.3390/diagnostics12092060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Mary Solou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Ioannis Ydreos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Maria Gavra
- Department of CT and MRI Imaging, “Agia Sofia” Hospital, 11527 Athens, Greece
| | - Evangelos K. Papadopoulos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Stamatis Banos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Efstathios J. Boviatsis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Georgios Savvanis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Lampis C. Stavrinou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
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De Jesus O, Monserrate AE. Burr Hole Surgery for Drainage of Chronic and Subacute Subdural Hematomas: Low Recurrence Rate in a Single Surgeon Cohort. Cureus 2021; 13:e19288. [PMID: 34900470 PMCID: PMC8648283 DOI: 10.7759/cureus.19288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available. Methods: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence. Results: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%. Conclusion: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.
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Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| | - Andres E Monserrate
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
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Singh J, Sobti S, Chaudhary A, Chaudhary V, Garg T. Comparative Study of Subgaleal and Subdural Closed Drain in Surgically Treated Cases of Chronic Subdural Hematoma. Asian J Neurosurg 2021; 16:96-98. [PMID: 34211874 PMCID: PMC8202380 DOI: 10.4103/ajns.ajns_101_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 09/06/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jagminder Singh
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Shivender Sobti
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Ashwani Chaudhary
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Vikram Chaudhary
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Tarun Garg
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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8
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Hanalioglu S, Bozkurt G, Isikay I, Mammadkhanli O. A simple and effective modified technique of twist drill craniostomy for bedside drainage and irrigation of chronic subdural hematoma: Technical and clinical study. Clin Neurol Neurosurg 2020; 199:106262. [PMID: 33031992 DOI: 10.1016/j.clineuro.2020.106262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/21/2020] [Accepted: 09/29/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is an important health problem observed mostly in elderly population. Here, we aimed to describe and validate a simple modified technique of twist-drill craniostomy (TDC) using easily accessible tools for effective and safe bedside CSDH drainage. METHODS A detailed description of the new modified TDC technique which allows for sequential drainage and irrigation under physiological conditions is provided. Clinical and radiological characteristics as well as surgical results of the patients undergoing this procedure are also presented. RESULTS A total of 55 patients (30 M, 25 F) underwent this modified TDC. Mean age was 61.7 ± 12.3 years. Medical comorbidities were common (76.4 %). Subdural hematoma was mostly unilateral (83.6 %). Maximum width of hematoma was 21 ± 4 mm on average (range: 9-38 mm). In total, patients underwent 1.6 ± 0.9 subdural tappings on average (median: 1, range: 1-5). Repeat tappings were performed in 43.6 % of the patients. No mortality, serious morbidity or infectious complications were noted. Pneumocephalus was either absent or minimal in most cases (96.4 %). Mean length of hospital stay was 4.9 ± 4.0 days (median: 3; range: 2-20 days). The clinical outcomes were favorable in 92.7 % of the patients (no craniotomy required and no symptomatic recurrence detected). CONCLUSION This modified technique of TDC utilizes easily available tools, yields satisfactory radiological and clinical results, allows repeated tappings even in outpatient settings and can thus be readily applied in every neurosurgical unit across the world. It can be an effective alternative to existing procedures for patients with multiple co-morbidities and/or high anesthesia risk, in emergency conditions and busy neurosurgical centers.
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Affiliation(s)
- Sahin Hanalioglu
- Hacettepe University Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey
| | - Gokhan Bozkurt
- Bahcelievler Memorial Hospital, Department of Neurosurgery, Istanbul, Turkey
| | - Ilkay Isikay
- Hacettepe University Faculty of Medicine, Department of Neurosurgery, Ankara, Turkey
| | - Orkhan Mammadkhanli
- Yuksek Ihtisas University Faculty of Medicine, Medical Park Ankara Hospital, Department of Neurosurgery, Ankara, Turkey.
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Wagner KE, Binyamin TR, Colley P, Chiluwal AK, Harrop JS, Hawryluk GW, Hickman ZL, Margetis K, Rymarczuk GN, Stippler M, Ullman JS. Trauma. Oper Neurosurg (Hagerstown) 2020; 17:S45-S75. [PMID: 31099847 DOI: 10.1093/ons/opz089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tamar R Binyamin
- Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California
| | - Patrick Colley
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amrit K Chiluwal
- Department of Neurosurgery, Northwell Health, Manhasset, New York
| | - James S Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Zachary L Hickman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Konstantinos Margetis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George N Rymarczuk
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.,Division of Neurosurgery, Walter Reed Medical Center, Bethesda, Maryland
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamie S Ullman
- Department of Neurosurgery, Northwell Health, Manhasset, New York
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10
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Kamenova M, Wanderer S, Lipps P, Marbacher S, Mariani L, Soleman J. When the Drain Hits the Brain. World Neurosurg 2020; 138:e426-e436. [DOI: 10.1016/j.wneu.2020.02.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
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Soleman J, Lutz K, Schaedelin S, Kamenova M, Guzman R, Mariani L, Fandino J. Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial). Neurosurgery 2019; 85:E825-E834. [DOI: 10.1093/neuros/nyz095] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes.
OBJECTIVE
To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD.
METHODS
Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay.
RESULTS
Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups.
CONCLUSION
Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice
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Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital of Basel, Basel, Switzerland
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Abdelfatah MAR. Recurrence Rate of Chronic Subdural Hematoma after Evacuating It by Two Large Burr Holes, Irrigation, and Subgaleal Low-Pressure Suction Drainage. Asian J Neurosurg 2019; 14:725-729. [PMID: 31497092 PMCID: PMC6702995 DOI: 10.4103/ajns.ajns_321_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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13
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Elayouty AED, AbdelFatah MA. Inner membrane opening during the burr-hole evacuation of a chronic subdural hematoma: risk-adding or recurrence-preventing? EGYPTIAN JOURNAL OF NEUROSURGERY 2018. [DOI: 10.1186/s41984-018-0003-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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14
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Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol 2018; 20:34. [PMID: 30019165 DOI: 10.1007/s11940-018-0518-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative. RECENT FINDINGS While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.
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Affiliation(s)
- Elena I Fomchenko
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA.
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Jason L Gerrard
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Clinical Neurosciences, Yale University, 20 York St, New Haven, CT, USA
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Suction forces generated by passive bile bag drainage on a model of post-subdural hematoma evacuation. Acta Neurochir (Wien) 2018; 160:1305-1309. [PMID: 29728776 DOI: 10.1007/s00701-018-3545-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Passive drainage systems are commonly used after subdural hematoma evacuation but there is a dearth of published data regarding the suction forces created. We set out to quantify the suction forces generated by a passive drainage system. METHOD We created a model of passive drainage after subdural hematoma evacuation. We measured the maximum suction force generated with a bile bag drain for both empty drain tubing and fluid-filled drain tube causing a siphoning effect. We took measurements at varying heights of the bile bag to analyze if bile bag height changed suction forces generated. RESULTS An empty bile bag with no fluid in the drainage tube connected to a rigid, fluid-filled model creates minimal suction force of 0.9 mmHg (95% CI 0.64-1.16 mmHg). When fluid fills the drain tubing, a siphoning effect is created and can generate suction forces ranging from 18.7 to 30.6 mmHg depending on the relative position of the bile bag and filled amount of the bile bag. The suction forces generated are statistically different if the bile bag is 50 cm below, level with or 50 cm above the experimental model. CONCLUSION Passive bile bag drainage does not generate significant suction on a fluid-filled rigid model if the drain tubing is empty. If fluid fills the drain tubing then siphoning occurs and can increase the suction force of a passive bile bag drainage system to levels comparable to partially filled Jackson-Pratt bulb drainage.
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