Single burr hole irrigation without drainage in chronic subdural hematoma

The surgical treatment of chronic subdural hematoma has evolved from membranectomy through craniotomy to burr hole irrigation. The latter approach is based on utilization of the natural absorptive process that is thought to be part of the life cycle of the hematoma. To test this theory, the authors treated fifty-nine patients with chronic subdural hematoma according to the following protocol. Local anesthesia was induced with a modified neuroleptanalgesic procedure. A single burr hole was drilled, usually in the posterior frontal region, and irrigation was carried out until the washing was clear. Subdural drainage was not employed. Patients were permitted to walk about on the following day. The outcome was better than that achieved with conventional treatment. Such complications as tension pneumocephalus and intracranial hematoma were not observed, and only one patient (1.7%) had a recurrence. The results of this study indicate that single burr hole irrigation without drainage is a very simple and effective treatment for chronic subdural hematoma. The absence of subdural drainage may be an important feature, since drainage may contribute to the development of certain postoperative complications. Also, the simplified procedure allows patients early mobility, which may be of particular benefit to the elderly.     

Comparing twist-drill drainage with burr hole drainage for chronic subdural hematoma

Objective

The surgical management of chronic subdural hematoma (CSDH) is still a controversial issue, and a standard therapy has not been established because of the unclear pathogenic mechanisms in CSDH. The intention of this paper is to find a simple and efficient surgical procedure for CSDH.

Methods

A retrospective study of 448 patients with CSDH by surgical treatment during 2005 to 2009 was conducted in order to compare the efficiency between two different primary surgical methods, i.e. twist-drill drainage with-out irrigation in Group A (n=178) and one burr-hole with irrigation in Group B (n=270). The results were statistically analyzed.

Results

The reoperation rates in Group A and Group B were 7.9% and 11.9% respectively. The good outcome rate was 88.8% and 75.5%, the complication was 7.9% and 20.7% in Group A and Group B, respectively.

Conclusions

The burr-hole drainage with irrigation of the hematoma cavity is not beneficial to the outcome and prognosis. Irrigation is not important in the surgical treatment for C S D H. Thus in initial treatment, twist-drill drainage without irrigation of the hematoma cavity is recommended because it is relatively safe, time-saving and cost-effective.     

Comparing twist-drill drainage with burr hole drainage for chronic subdural hematoma

Objective: The surgical management of chronic subdural hematoma (CSDH) is still a controversial issue, and a standard therapy has not been established because of the unclear pathogenic mechanisms in CSDH.The intention of this paper is to find a simple and efficient surgical procedure for CSDH.Methods: A retrospective study of 448 patients with CSDH by surgical treatment during 2005 to 2009 was conducted in order to compare the efficiency between two different primary surgical methods, i.e. twist-drill drainage without irrigation in Group A (n=178) and one burr-hole with irrigation in Group B (n=270). The results were statistically analyzed.Results: The reoperation rates in Group A and Group B were 7.9% and 11.9% respectively. The good outcome rate was 88.8% and 75.5%, the complication was 7.9% and 20.7% in Group A and Group B, respectively.Conclusions: The burr-hole drainage with irrigation of the hematoma cavity is not beneficial to the outcome and prognosis. Irrigation is not important in the surgical treatment for CSDH. Thus in initial treatment, twist-drill drainage without irrigation of the hematoma cavity is recommended because it is relatively safe, time-saving and cost-effective.     

Remote cerebellar hemorrhage after single burr hole drainage of chronic subdural hematoma of the elderly

Remote cerebellar hemorrhage is a usual complication after supratentorial craniotomy. Especially, only several cases have been reported regarding the occurrence of remote cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (CSDH). In this paper, we present an elder patient with this rare postoperative complication. A 73-year-old man presented with dysarthria and right hemiparesis. Computed tomography (CT) demonstrated a left chronic subdural hematoma. Hematoma drainage through a single burr hole was perfomed. About 3 hours after the surgery, the patient became restless and presented nausea and dizziness with a relatively large amount of drainage of hematoma. CT revealed resolution of the subdural hematoma and bilateral cerebellar hemorrhage appearing as "zebra sign". Magnetic resonance angiography and 3D-CT angiography showed the normal structure of posterior circulation in both the arterial and venous phases. The remote cerebellar hemorrhage was suspected to have happened as a result of overdrainage of hematoma. Finally, he was discharged without any neurological deficits. Although remote cerebellar hemorrhage after drainage through a burr hole for the treatment of chronic subdural hematoma is a rare complication, it is necessary to be aware of the possibility of such a complication after supratentorial surgery.     

Contralateral development of chronic subdural hematoma after evacuation of chronic subdural hematoma. A case report

Contralateral acute complications such as acute epi/subdural hematomas can be encountered after evacuation of a chronic subdural hematoma, though they are rare. We found only one case of chronic subdural hematoma following the surgery for contralateral chronic subdural hematoma, have been published in English language literature. A 73-year-old male admitted to our hospital with a right-sided subdural hematoma. The subdural hematoma was evacuated through a burr-hole. A left-sided subdural higroma appeared after operation and turned into classical subdural hematoma in the course of time. After evacuation of contralateral chronic subdural hematoma, the patient recovered completely. All stages of the development of contralateral chronic subdural hematomas were shown by serial computed tomograms. It was suggested that traumatic chronic subdural hematomas develop from mostly subdural higromas. If contralateral subdural higroma is seen after surgical evacuation of a chronic subdural hematoma, the possibility of development of contralateral chronic subdural hematoma must be kept on mind.     

Intracerebral hematoma following evacuation of chronic subdural hematoma

The prognosis after evacuation of a chronic subdural hematoma is generally good, yet occasionally post-operative complications do occur. Intracerebral hematoma following such evacuation is rare and two cases are reported. It is suggested that this complication could be due to the disturbances of intracerebral vascular homeostatis occurring after rapid evacuation of subdural hematomas where there has been a large shift of the brain stem.     

Single burr hole evacuation for traumatic acute subdural hematoma of the posterior fossa in the emergency room

A 57-year-old man and a 55-year-old man presented with acute subdural hematoma of the posterior cranial fossa due to trauma. Both were comatose preoperatively. Emergent single burr hole evacuation in the posterior cranial fossa was performed in the emergency room immediately after computed tomography. Neurological symptoms improved dramatically just after initiating the burr hole evacuation in both patients. A 57-year-old man became alert and could walk unassisted 1 month after surgery. The other could walk with assistance 4 months after surgery, although psychic disturbance resulting from cerebral contusion remained. Single burr hole evacuation in the emergency room is a useful treatment for acute subdural hematoma of the posterior cranial fossa because the procedure can be performed easily and rapidly, thus achieving reduction of intracranial pressure. Progressing neurological deterioration, reversibility of brainstem function by mannitol administration and the sign of brainstem compression and noncommunicating hydrocephalus are good indicators for this treatment.     

改良钻孔冲洗引流术治疗慢性硬膜下血肿160例

慢性硬膜下血肿（CSDH）是神经外科常见疾病,而钻孔冲洗引流术是目前公认的治疗CSDH的首选方法。但该方法仍存在一定的复发率为3．7％～38％．本院就2002年1月至2008年3月收治的此类单侧血肿病人160例．通过对比研究,认为采用本院的改良钻孔冲洗引流术能有效减轻术后颅内积气程度,并降低CSDH复发率。     

An implantable subdural drain for treatment of chronic subdural hematoma

We describe a drain that is implanted at operation for a chronic subdural hematoma. The drain provides access to the subdural space and can therefore be used for percutaneous aspiration of reaccumulation of subdural effusions.     

Safety of early warfarin resumption following burr hole drainage for warfarin-associated subacute or chronic subdural hemorrhage

The primary objective of this study was to evaluate the safety of early warfarin resumption following burr hole drainage for warfarin-associated subdural hemorrhage (SDH). This prospective, single-arm, single-center trial was conducted from February 2008 to April 2010. Inclusion criteria were premorbid warfarin therapy, subacute or chronic SDH requiring burr hole drainage, and an International Normalized Ratio (INR) of >1.5 at presentation. Three days after surgery, warfarin was re-administered to reach the target INR range of 1.7-2.5. Patients were followed by regular INR monitoring and serial brain CT scans, which were performed at 1 week, and at 1, 3, and 6 months after surgery. The primary outcome was recurrent SDH incidence. Twenty patients were enrolled and CT scans performed at 1 week revealed no new intracranial hemorrhage in any patient. Subsequent scans were performed at 1 month on 19 patients, and recurrent SDH was observed in three. However, this recurrence rate (15.8%; 95% CI 0,34) did not exceed that of ordinary SDHs, and all recurrent SDHs were successfully managed by repeated burr hole drainage. The other 16 patients completed their 6-month follow-ups uneventfully. SDH recurrence was found to be associated with older age (≥ 75 years), and a thicker SDH (≥ 25?mm), but not with post-operative anticoagulation status. None of the study subjects experienced a thromboembolic event during the study period. Restarting warfarin therapy does not need to be withheld for more than 3 days after burr hole drainage, particularly in patients with a high thromboembolic risk.     

Combined epidural and intracerebral hematomas after evacuation of bilateral chronic subdural hematoma

Bleeding after surgery for chronic subdural hematoma far from the operative site is a rare phenomenon with possibly serious consequences. We report a case of combined epidural and intracerebral hemorrhage immediately after evacuation of bilateral chronic subdural hematoma. The epidural hematoma was evacuated by emergency craniotomy, but the deep parenchymal hematoma was treated conservatively. The patient recovered progressively with a good outcome. Approximately 30 cases of chronic subdural hematomas complicated by intracerebral hematoma were previously reported, but only seven cases of epidural hematoma. These complications could be avoided if slow, gradual decompression is used during surgery. Clinicians should suspect its occurrence without delay when a postoperative neurological deterioration is demonstrated. Possible mechanisms are discussed.     

氨甲环酸联合钻孔引流术治疗慢性硬膜下血肿

目的研究慢性硬膜下血肿钻孔引流术联合血肿腔内应用氨甲环酸对慢性硬膜下血肿(CSDH)术后复发率的影响。方法采用前瞻性随机对照研究,将本院近2年内慢性硬膜下血肿50例随机分为实验组和对照组,每组25例。实验组行钻孔引流术,同时血肿腔注入氨甲环酸治疗,对照组仅行钻孔引流术,其它常规治疗两组均相同。分别检测两组患者手术冲洗前后血肿液及手术后血肿腔引流液的D-二聚体,术后随访6个月,分析复发率。结果两组患者血肿液D-二聚体在术中冲洗前均高于正常,在术中冲洗后均降低,两组比较均无统计学差异(P>0.05)。术后2天,实验组血肿腔引流液D-二聚体显著低于对照组,统计有显著差异(P<0.05)。50例患者术后均全部治愈出院,实验组25例有2例复发,对照组有8例复发,实验组复发率显著低于对照组,统计有显著差异(P<0.05)。结论血肿腔局部纤溶功能亢进在慢性硬膜下血肿发病机制及复发中起重要作用,术中氨甲环酸在血肿腔内局部应用可抑制其纤溶功能亢进,显著降低术后血肿腔引流液D-二聚体浓度,从而显著降低慢性硬膜下血肿患者的术后复发率,值得临床推广应用。     

Treatment of chronic subdural hematoma by burr holes and closed-system drainage

This article highlights the treatment of choice of chronic subdural hematoma. The importance, effectiveness, and low complication rate of minimally invasive procedure by burr holes and closed-system drainage is discussed.     

急性硬膜下血肿清除术后迟发性硬膜下积液的诊治

目的 探讨急性硬膜下血肿清除术后硬膜下积液的原因、早期诊断、手术治疗方法和疗效。方法 对急性硬膜下血肿后硬膜下积液29例进行回顾性分析。结果 痊愈14例，占48．7％；轻残5例，占17．2％；重残4例，占13．8％；植物状态3例，占10．3％，死亡3例，占10．3％。引流效果良好，无一例颅内感染。结论 急性硬膜下血肿清除后可能发生硬膜下积液；术后意识无改善或意识好转后又加重、出现颅内压增高征象、神经系统定位体征、减压区膨隆、瞳孔及生命体征改变应予CT检查可明确诊断：积液区颅骨钻孔或减压区小切口置管引流简便易行，有效满意疗效。     

A comparative study of the treatment of chronic subdural hematoma—burr hole drainage versus burr hole irrigation

BACKGROUND

Several surgical procedures have been reported for the treatment of chronic subdural hematoma. Whether irrigation is required is not clear. We compared the results of treatment of chronic subdural hematoma obtained with burr hole drainage and burr hole irrigation retrospectively.

METHODS

Forty patients with chronic subdural hematoma underwent surgery at our institution in the last 3 years. The first 20 patients were treated by burr hole irrigation (irrigation group), while the last 20 patients underwent burr hole drainage (drainage group). The rates of recurrence, changes in hematoma size, and number of days of postoperative hospitalization for the two groups were compared. No significant differences were found between the two groups in the presence of head injury, alcohol consumption, age, gender, or preoperative hematoma size.

RESULTS

Duration of postoperative hospitalization was 14.1 days in the drainage group and 25.5 days in the irrigation group. Recurrence was observed in 1 case (5%) in the drainage group, and in 5 cases (25%) in the irrigation group. In the drainage group, postoperative hematoma size was significantly decreased compared to preoperative hematoma size on the first postoperative day, after which change in hematoma size was minimal. On the other hand, in the irrigation group, hematoma size was decreased on the first postoperative day, but not to a significant extent.

CONCLUSION

For treatment of chronic subdural hematoma, postoperative hospitalization was shorter and the recurrence was less frequent with drainage than with irrigation.     

Chronic subdural haematomas: a comparative study of an enlarged single burr hole versus double burr hole drainage

Various surgical treatments have been proposed for the treatment of chronic subdural haematoma (CSDH). Herewith, we set out to compare the efficacy of an enlarged single burr hole versus double burr hole drainage for the treatment of CSDH. We studied patients with symptomatic CSDH proven by CT scan that were treated in our institute between January 2002 and January 2009. All patients were treated by an enlarged single or double burr hole drainage. A subdural drain was placed in all cases. A total of 245 patients were included in the study. Double hole drainage was performed in 156 (63.7 %) patients (group A) and an enlarged single burr hole drainage in 89 (36.3 %) patients (group B). There were nine recurrences in group A and five in group B; however, the difference was not statistically significant. There was no significant relationship between recurrence rate and age, gender, bilateral haematoma and antiplatelet or anticoagulant therapy. There was a trend towards higher risk of recurrence for patients with residual clots on postoperative CT scan. The mean hospitalization time was 6.2 days, and there was no significant difference between the two groups. No significant difference was found between patients' outcome, as assessed by Glasgow outcome scale score, and treatment method. Enlarged single burr hole and double burr hole drainage had the same efficacy in the treatment of CSDH.