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.     

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.     

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.     

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.     

Two cases of impending herniation due to multiple traumatic acute subdural hematomas: combination of burr hole evacuation and craniotomy

A contralateral extra-axial hematoma sometimes occurs during an operation on an acute subdural hematoma and may become fatal. Using a combined procedure of burr hole evacuation and craniotomy, we treated 2 cases of multiple traumatic acute subdural hematomas. Our policy for such cases is first to perform a burr hole evacuation for the acute subdural hematoma in the emergency room, while simultaneously preparing the operation room for a possible further operation. Next, we perform computed tomography (CT) of the brain. If the evacuation does not provide enough decompression, we either carry out a craniotomy at the same site, or, we observe the patient without resorting to craniotomy. However, if the patient's condition deteriorates, burr hole evacuation is repeated and/or craniotomy is carried out as soon as possible on the lesion at the already prepared operation room. Both of our patients received craniotomy for another subdural hematoma after the burr hole evacuation. Though his intracranial pressure was well managed during the acute stage, one of the patients died 21 days after the trauma due to an extensive brain infarction caused by vasospasm. The other regained consciousness and was able to walk 5 months after the trauma in spite of cerebral infarction from vasospasm. The possible mechanism of vasospasm in severe head injury is also discussed.     

Treatment of chronic subdural hematoma by twist-drill craniotomy with continuous catheter drainage

The case records of 114 patients were reviewed to ascertain the efficacy of bedside twist-drill craniotomy and continuous closed-system catheter drainage for the treatment of chronic subdural hematomas. Ninety-eight (86%) patients achieved an excellent outcome, and seven (6%) had no significant improvement. The total mortality from all cases was 8% in this group. Successful catheter drainage of the chronic subdural hematoma was accomplished by either one or two catheter placements in 102 (90%) patients. Twelve patients required additional operative procedures. The mean duration of hospitalization for the study group was 16 days. No infections occurred in these patients. Remission of the clinical syndrome did not require the radiographic resolution of the chronic subdural hematoma.     

Chronic subdural hematomas

Zusammenfassung Es wird an Hand klinischer und histologischer Untersuchungsergebnisse die Existenz chronischer, gekapselter subduraler Hämatome traumatischer Genese bestätigt und klar herausgestellt, daß sich dieses Krankheitsbild streng von dem der intraduralen Blutungen bei Pachymeningitis haemorrhagica interna trennen läßt. Weiter wird kurz auf die Diagnostik des Krankheitsbildes eingegangen und ein Überblick über die Möglichkeiten der Behandlung und die Indikationsstellungen hierzu gegeben. Hervorgehoben wird vor allem, daß Beobachtungen und Untersuchungen bezüglich des Entstehungsmechanismus der subduralen Hämatome zweifelsfrei erkennen lassen, daß es sich dabei um eine Blutung ex vacuo handelt, als deren auslösende Faktoren Durchblutungsstörungen und intrakranielle Druckschwankungen (Unterdruck!) als Traumafolge anzusehen sind. Es werden noch vergleichende Untersuchungsergebnisse über Liquordruckmessungen bei gekapselten, chronischen subduralen Hämatomen und intraduralen Blutungen angeführt und auf die unterschiedliche Alters- bzw. Geschlechtsverteilung des Krankheitsbildes hingewiesen.

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Summary Based on clinical and histological examinations, the existence of chronic capsular subdural hematomas of traumatic genesis is confirmed and it is pointed out that this clinical picture may be well distinguished from the one with intradural hemorrhage in hemorrhagic pachymeningitis. Besides, the A. briefly discusses the diagnosis of the clinical picture giving a review of the therapy. Above all he points out that the observations and researches regarding the mechanism of the development of subdural hematomas doubtlessly show that it is the result of a hemorrhage ex vacuo, the determinant factors of which are to be considered the disturbance of circulation and the oscillation of endocranial pressure (hypotension!). The A. also refers on the results of comparative measuring of the liquor pressure in chronic capsular subdural hematomas and in intradural hemorrhages, and indicates their classification regarding age and sex.

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Resumen En base a los examenes clinicos y istologicos, se conferma la existencia de ematómas subdurales capsuláres cronicos de genesis traumatica y se pone en evidencia que este cuardro clinico puede ser bien separado de aquello con emoragias entradurales en la paquiminingitis. Ademas se habla en corto de la diagnosis de el cuadro clínico haciendo una revista de el tratamiento. Se pone en evidencia sobre todo que las observaciones y indagaciones concernientes el mecanismo de el desarollo de los ematomas subdurales permiten sin duda el reconocimiento de que se trata de el resultado de una emoragía ex-vacuo; los factores determinantes son da eonsiderarse las molestias de circolo y las oscilaciones de la presión endocranica (ipotensión). El autor da noticias también de los resultados de las misuraciones comparativas de la presión licorál en el ematoma subdurál capsurál cronico, en las emoragiás entradurales y se hace alusión a la frecuencia con relación a la edad y al sexo.

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Résumé Sur la base des examens cliniques et histologiques, on confirme l'existence d'hématomes subduraux capsulaires chroniques d'origine traumatique et l'on met en évidence que cet aspect clinique peut facilement être distinct de celui avec hémorragies intradurales dans la pachyméningite hémorragique. En outre, on discute brièvement le diagnostic de l'aspect clinique, en faisant une revue du traitement. On met surtout en évidence que les observations et les recherches concernant le mécanisme du développement des hématomes subduraux permettent, sans le moindre doute, de reconnaître qu'il s'agit du résultat d'une hémorragie ex-vacuo; les troubles de circulation et les oscillations de la pression endocrânienne (hypotension) doivent être considérés comme les facteurs déterminants de cette hémorragie. L'A. parle aussi des résultats des mensurations comparatives de la pression liquorale dans l'hématome subdural capsulaire chronique, dans les hémorragies intradurales, et il fait allusion à la répartition par rapport à l'âge et au sexe.

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Riassunto In base agli esami clinici ed istologici si conferma l'esistenza di ematomi subdurali capsulari cronici di genesi traumatica e si mette in evidenza che questo quadro clinico può essere ben distinto da quello con emorragie intradurali nella pachimeningitis emorragica. Inoltre si discute brevemente la diagnosi del quadro clinico, facendo una rassegna del trattamento. Si mette in evidenza sopratutto che le osservazioni e indagini riguardanti il meccanismo dello sviluppo degli ematomi subdurali permettono senza dubbio il riconoscimento che si tratti del risultato di una emorragia ex vacuo, i cui fattori determinanti sono da considerare i disturbi di circolo e le oscillazioni della pressione endocranica (ipotensione!). L'A. dà notizia anche dei risultati delle misurazioni comparative della pressione liquorale nell'ematoma subdurale capsulare cronico, nelle emorragie intradurali, e si accenna alla distribuzione in rapporto all'età ed al sesso.

     

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 haematoma treated by burr holes and closed system drainage: personal experience in 131 patients.

One-hundred and thirty-one patients with chronic subdural haematoma were treated by burr holes and closed system drainage. Four patients died, and in 19 patients postoperative complications were noted: intracranial hypotension in eight, cerebral oedema in four, haematoma recurrence in three, bronchopneumonia in three, and intracerebral haematoma in one. The high risk groups were those in grade III and IV on admission, and the elderly. Follow-up revealed that more than 80% of patients recovered completely, 10% still had neurological or mental deficits and 7% suffered epileptic seizures.     

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.     

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。     

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。     

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.