Outcome of contemporary surgery for chronic subdural haematoma: evidence based review

OBJECTIVE: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. METHODS: A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty. RESULTS: 48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation). CONCLUSIONS: The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.     

Prospective analysis of bedside percutaneous subdural tapping for the treatment of chronic subdural haematoma in adults

OBJECTIVES: Although there is general agreement that surgery is the best treatment for chronic subdural haematoma (CSDH), the extent of the surgical intervention is not well defined. METHODS: The less invasive surgical technique of bedside percutaneous subdural tapping and spontaneous haematoma efflux after twist drill craniostomy under local anaesthesia was prospectively analysed in 118 adult patients, 99 with unilateral and 19 with bilateral CSDH. RESULTS: The mean number of subdural tappings was 3.2. Ninety two of the patients with unilateral CSDH were successfully treated by up to five subdural tappings, 95% of the patients with bilateral CSDH were successfully treated by up to 10 subdural tappings. The mean duration of inpatient treatment was 12 days. In 11 patients (9%) the treatment protocol had to be abandoned because of two acute subdural bleedings, two subdural empyemas, and seven cases of insufficient haematoma efflux and no neurological improvement. The only significant predictor for failure of the described treatment protocol was septation visible on preoperative CT. CONCLUSIONS: The described therapy protocol is-apart from a purely conservative treatment-the least invasive presently available surgical technique for treating chronic subdural haematoma. Its results are comparable with other modern treatment protocols. Thus, it can be recommended in all patients as a first and minimally invasive therapy, especially in patients in a poor general condition. Patients with septation visible on preoperative CT should be excluded from this form of treatment.     

双侧慢性硬膜下血肿的诊治体会

目的探讨双侧慢性硬膜下血肿的诊治特点。方法26例高龄双侧慢性硬膜下血肿,全部病例均行头颅CT检查。2例在全麻下,其它在局麻下采取双侧钻单孔引流术。选定血肿最厚层面前中1／2到1／3处为钻孔点。结果漏诊一侧1例,其余术前诊断正确。25例术后痊愈,1例原有神经功能恢复不明显。结论仔细观察CT和选定合适的钻孔点是诊治的关键。     

Interhemispheric subdural hematoma: an uncommon sequel of trauma

Interhemispheric subdural hematomas are relatively uncommon and usually seen in patients with bleeding disorders. They may present with signs of the falx syndrome or seizures. The management options range from craniotomy and evacuation to conservative management. We report such a case in a patient with normal bleeding parameters, which was managed with a twist drill craniostomy and drainage of the hematoma.     

双侧慢性硬膜下血肿的微创治疗

目的 探讨双侧慢性硬膜下血肿的诊治方法及效果.方法 回顾性分析2001-04～2006-05收治的28例双侧慢性硬膜下血肿的临床资料,首诊即行颅脑CT检查22例（79%）,MRI检查16例（57%）.首诊误诊3例,漏诊1例.28例术前诊断均正确.治疗方法均采取局麻下行双侧钻单孔冲洗引流术.结果 27例术后均痊愈,1例出现硬膜下积液,全组无死亡病例.结论 双侧慢性硬膜下血肿确诊的首选方法是颅脑CT,必要时辅以MRI检查;双侧钻单孔微创术为首选治疗方法,效果良好.     

Endoscopic-assisted evacuation of subdural collections

Treatment of chronic subdural haematoma (SDH) using endoscopic-assisted techniques is a minimally invasive method that may provide an addition to the standard technique of burr-hole craniostomy drainage.Over a 12-month period the authors used endoscopic assistance with burr-hole craniostomy drainage, and prospectively collected data to review the technique. Ten patients were treated during the study, with an average age of 67. Subsequent to the study, one further procedure was performed on a 79-year-old man.Although endoscopic assistance did not alter the intra-operative plan in most patients, it did assist with inserting a subdural catheter for washout of the subdural space, assessing for multi-loculation of the SDH and providing visual images that were captured for discussion with the patient/family and for later study. In one patient, endoscopy assisted with the visualisation and destruction of neomembranes.We conclude that the technique is unlikely to alter the surgeon’s pre-operative or intra-operative plan; however, in selected circumstances, it could make the procedure safer with enhanced intra-operative visualization and may also allow for the identification and destruction of neomembranes or solid clots under direct vision.     

Contralateral acute epidural haematoma following evacuation of a chronic subdural haematoma with burr-hole craniostomy and continuous closed system drainage: a rare complication

Chronic subdural haematoma (CSDH) is one of the most frequent causes for neurosurgical intervention. Although the prognosis is generally good and treatment modalities are well established, some devastating intracranial haematomas can complicate its evacuation. The authors report here a case of an acute epidural haematoma occurring after evacuation of a contralateral chronic subdural haematoma (CSDH) with burr-hole craniostomy and continuous closed system drainage without irrigation. Since this is a rare, but potentially life-threatening, complication, clinicians should suspect its occurrence when an unexpected postoperative course is demonstrated.     

双针穿刺治疗老年患者慢性硬膜下血肿

目的 总结30例经皮双针穿刺引流治疗老年患慢性硬膜下血肿效果，探讨慢性硬膜下血肿治疗方法。方法 本组30例慢性硬膜下血肿均经CT检查确诊，都行经皮双针穿刺引流术。结果 所有病例术后l～3d复查CT，血肿腔缩小90％以上，除10例有颅内积气外，未见颅内血肿、颅内感染、肺部感染和其它并发症。术后3～7d拔针，穿刺点一期愈合，痊愈出院，随访6-24月未见复发。结论 经皮双针穿刺引流治疗慢性硬膜下血肿是一种微创、简单、高效和并发症少的方法，但穿刺针需要作改进。     

Burr-hole versus twist-drill drainage for theevacuation of chronic subdural haematoma:a comparison of clinical results

BACKGROUND: Most neurosurgeons remove clinically symptomatic subdural haematomata, but the techniques they choose remain controversial. METHOD: The results from sixty-two patients diagnosed with chronic subdural haematoma were evaluated for technique, postoperative computerized tomography (CT) scan results, and complications. RESULTS: Eleven patients had haematomata evacuated using twist-drill plus drain, 37 patients had haematomata evacuated with burr-hole only, and 14 patients were evacuated with burr-hole plus drain. Of the patients who underwent twist-drill and closed system drainage (CSD), 43% had smaller lesions on CT follow-up scans, as compared with 74% of those who underwent the burr-hole only procedure, and 65% with burr-holes with drains. Clinical outcome results showed that 64% of twist-drill and CSD patients deteriorated as compared with 16% of those with burr-hole only and 7% with burr-holes and CSDs. Sixty-four per cent of twist-drill patients required repeat evacuations as compared with 11% of those with burr-holes only, and 7% with burr-holes plus drains. CONCLUSION: The results at our institution indicate that burr-hole evacuation for chronic subdural haematoma is superior to twist-drill evacuation with respect to clinical outcomes and complications.     

Chronic subdural haematoma preceded by persistent traumatic subdural fluid collection.

The role of traumatic subdural fluid collections in the development of chronic subdural haematomas was studied in 43 of 715 patients who underwent a CT scan because of a recent head injury. Twenty of the 43 patients subsequently developed a chronic subdural haematoma, and this occurred especially in the aged. Nearly 50% of patients with asymptomatic or minimally symptomatic subdural fluid collection may develop a chronic subdural haematoma.     

Chronic subdural haematoma complicating spinal anaesthesia

Abstract Cranial subdural haematoma formation following spinal anaesthesia is exceptionally rare. A 38-year-old male developed headache two days after testicular surgery under spinal anaesthesia. The headache progressed in spite of analgesics, and three weeks later cranial CT showed a large chronic subdural haematoma in the left fronto-parietal region. The patient improved after surgical decompression. The pathogenesis of subdural haematoma formation after dural puncture is discussed and the literature briefly reviewed. Prolonged and severe post-dural puncture headache should be viewed with suspicion and investigated promptly to rule out any intracranial complication.     

Contralateral acute subdural hematoma occurring after evacuation of subdural hematoma with coexistent contralateral subdural hygroma

Burr-hole craniostomy with closed-system drainage is a safe and effective method for the management of chronic subdural hematoma. However, contralateral acute subdural hematoma has been reported to be a rare and devastating complication. Only 3 cases have been described in the literature. Herein, we reported an 80-year-old male with chronic subdural hematoma and contralateral subdural hygroma. The burr-hole craniostomy with closed-system drainage was initially performed to treat the chronic subdural hematoma. Three days after surgery, weakness of the extremities developed, and contralateral acute subdural bleeding within the previous subdural hygroma was diagnosed by CT scan of the brain. The pathophysiological mechanism of this rare complication was discussed, and the relevant literature was also reviewed.Chronic subdural hematoma (SDH) is one of the most common entities managed in daily neurosurgical practice, and is known to have a good prognosis after minimal burr-hole craniostomy.1 Ipsilateral acute SDH or recurrence of hematoma is the most well-documented complication of this simple surgery.1-3 However, the development of a contralateral acute SDH following burr-hole craniostomy with closed-system drainage has been previously reported to be a rare but devastating postoperative complication.4,5 Herein, we report a case of contralateral acute SDH occurring after evacuation of chronic SDH with the coexistence of contralateral subdural hygroma. The relevant literature is also reviewed. Our objective in presenting this particular case is to highlight this rare but devastating complication in the management of this disease.     

Chronic Subdural Hematomas : A Comparative Study of Three Types of Operative Procedures

Objective

Several surgical procedures have been reported for the treatment of chronic subdural hematoma (CSDH). We compared the results of treatments for CSDH obtained from one burr-hole craniostomy with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation, and small craniotomy with irrigation and closed-system drainage.

Methods

Eighty-seven patients with CSDH underwent surgery at our institution from January 2004 to December 2008. Our patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n = 25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n = 32), and group III, small craniotomy with irrigation and closed-system drainage (n = 30).

Results

Age distribution, male and female ratio, Markwalder''s grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer.

Conclusion

Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH.     

Management of chronic subdural hematoma: a national survey and literature review

OBJECTIVE: To survey neurosurgical practices in the treatment of chronic and subacute subdural hematoma in the Canadian adult population. METHODS: We developed and administered a questionnaire to Canadian Neurosurgeons with questions relating to the management of chronic and subacute subdural hematoma. Our sampling frame included all neurosurgery members of the Canadian Neurosurgical Society. RESULTS: Of 158 questionnaires, 120 were returned (response rate = 76%). The respondents were neurosurgeons with primarily adult clinical practices (108/120). Surgeons preferred one and two burr-hole craniostomy to craniotomy or twist-drill craniostomy as the procedure of choice for initial treatment of subdural hematoma (35.5% vs 49.5% vs 4.7% vs 9.3%, respectively). Craniotomy and two burr-holes were preferred for recurrent subdural hematomas (43.3% and 35.1%, respectively). Surgeons preferred irrigation of the subdural cavity (79.6%), use of a subdural drain (80.6%), and no use of anti-convulsants or corticosteroids (82.1% and 86.6%, respectively). We identified a lack of consensus with keeping patients supine following surgery and post-operative antibiotic use. CONCLUSION: Our survey has identified variations in practice patterns among Canadian Neurosurgeons with respect to treatment of subacute or chronic subdural hematoma (SDH). Our findings support the need for further prospective studies and clinical trials to resolve areas of discrepancies in clinical management and hence, standardize treatment regimens.     

Successful treatment of acute subdural haematoma associated with severe bleeding disorder

Summary A 76-year-old man suffering from myelofibrosis with thrombocytopenia sustained an acute subdural haematoma with severe neurological deficit. He was treated initially by bedrest and dexamethasone. Craniotomy was contraindicated because his bleeding time exceeded 20 min in spite of multiple infusions of platelet concentrate. After 3 weeks his condition deteriorated with increase of the fluid collection shown by CT. Partial drainage of the haematoma by subdural puncture with a 22-gauge spinal needle resulted in complete recovery from the neurological deficit and complete resorption of the effusion. The case shows that it is possible to avoid craniotomy in the acute phase of a subdural haematoma in patients with bleeding disorders and that it may be advantageous to use needle evacuation instead of burr-hole drainage in the chronic phase.     

A safe and effective method for treatment of chronic subdural haematoma

OBJECTIVE: Burr-hole irrigation and burr-hole drainage without irrigation are the most popular methods for treatment of chronic subdural haematoma. It is not well known if irrigation is necessary or which method has a higher recurrence rate. We compared the recurrence rates of those two methods. MATERIALS AND METHODS: Forty-two patients were treated by burr-hole irrigation (irrigation group), whereas 38 patients were treated by burr-hole drainage (drainage group). Recurrence rate and its relation with sex, age, haematoma localization and aetiology were investigated in both groups. RESULTS: There was no significant difference between recurrence rates of the two groups. There was also no correlation between recurrence rate and age, sex, haematoma localization, or aetiology. CONCLUSIONS: There was no significant difference between recurrence rates of the two groups. Since the burr-hole drainage method is simpler to carry out, its use may be preferable.     

Chronisches subdurales Hämatom bei Patienten unter 35 Jahren

OBJECTIVE: Although chronic subdural haematoma (CSDH) is considered a condition of the elderly, it may also occur in younger patients. The objective of this study was to identify the cause of CSDH in younger patients. METHOD: In a group of 100 consecutive patients with CSDH diagnosed in our hospital between 1 January 2000 and 31 August 2003, we found nine patients to be younger than 35. These nine were assessed to identify their cause of CSDH. RESULTS: We found a predisposing cause in five of nine patients, three having a disorder of CSF balance, and two having a clotting disorder. Trauma was reported in only two of these five patients. Among the four patients without a predisposing factor a trauma was reported in three of them. In only one patient the cause of CSDH remained unknown. All patients made a complete recovery. CONCLUSION: Chronic subdural haematoma did also occur in younger patients. Trauma, CSF imbalance, and deranged clotting increase the risk of CSDH, however this disorder can also occur in the absence of identifiable predisposing factors or trauma.     

Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage.

Recurrence of chronic subdural hematoma after burr-hole craniostomy and closed system drainage is not uncommon. We sought to identify risk factors for recurrence. In 121 patients, various factors including age, initial neurologic status, hematoma thickness, computed tomographic density of the hematoma, midline shift, multiplicity, systemic disease, and drainage volume were compared retrospectively between nonrecurring cases and recurring cases. Recurrence was noted in 10 cases (8.3%). In recurring cases, the drainage volume was significantly larger than in nonrecurring cases, and the recurrence rate increased in proportion to drainage volume. Other factors significantly influencing recurrence were hematoma thickness and associated diabetes mellitus. Drainage contents mainly derived from either exudate within the subdural membrane or cerebrospinal fluid leakage. Entry of cerebrospinal fluid into the hematoma cavity or continuing leakage of serum components through opened endothelial gap junctions are considered to be major causes of increased drainage volume, leading in turn to recurrence of the hematoma.     

Indications and Surgical Results of Twist-Drill Craniostomy at the Pre-Coronal Point for Symptomatic Chronic Subdural Hematoma Patients

Objective

Twist-drill craniostomy (TDC) with closed-system drainage and burr-hole drainage (BHD) with a closed system are effective treatment options for chronic subdural hematoma (CSDH). The aim of this study was to analyze clinical data and surgical results from symptomatic CSDH patients who underwent TDC with closed-system drainage at the pre-coronal point (PCP).

Methods

We analyzed data for 134 symptomatic CSDH patients who underwent TDC at the PCP with closed-system drainage. We defined the PCP for TDC to be 1 cm anterior to the coronal suture at the level of superior temporal line. TDC at the PCP with closed-system drainage was selected in patients with CSDH that extended beyond the coronal suture, confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed retrospectively.

Results

Of the 134 CSDH patients, 114 (85.1%) showed improved clinical performance and imaging findings after surgery. Catheter failures were seen in two cases (1.4%); the catheters were inserted in the epidural space. Recurrent cases were seen in eight patients (5.6%), and they were improved with a second BHD with a closed-system operation.

Conclusion

TDC at the PCP with closed-system drainage is safe and effective for patients with symptomatic CSDH whose hematomas extend beyond the coronal suture.     

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

ObjectiveTo 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.MethodsWe 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.ResultsOf 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.ConclusionBoth 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.