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.     

Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach

The objective of this paper was to evaluate whether available evidence supporting placement of subdural drain placement after evacuation of chronic subdural haematoma (CSDH) is applicable to a cohort of patients managed by us. In this observational cohort study, clinical follow-up was obtained in 166 patients who underwent burr hole evacuation of CSDH without placement of subdural drain followed by 3 days of bed rest. The primary outcome studied was recurrence requiring reoperation. Factors predicting recurrence were also analysed. We compared the patient characteristics and management protocols in our cohort with that in reports supporting drain placement to determine whether such evidence is relevant to our patient group. The mean age of our patients was 58 ± 17 years (range, 1 to 89 years). Sixteen of the 166 (9.6%) patients presented with symptomatic recurrence. The median time to reoperation for recurrence (15 of 16 patients) after the primary procedure was 17 days (range, 2 to 68 days). Antiplatelet and anticoagulant therapy was the only factor that was significantly associated with recurrence (p = 0.01). There were no infective or non-infective complications in our patient cohort. Our patient cohort and outcomes differed from those reporting drain placements in the following parameters: they were a decade younger, all patients received bed rest for 3 days after surgery and the recurrence rate was similar to that reported in the drained groups but significantly less than that reported in the non-drained groups. Routine placement of drain following burr hole evacuation of CSDH should only be done after careful comparison of the patient cohort under consideration and those reporting superior outcomes with drains. Evidence-based medicine supports such an approach.     

Continuous irrigation-drainage of the subdural space for the treatment of chronic subdural haematoma. A prospective clinical trial

Summary Thirty seven adult patients which chronic subdural haematoma were randomized into two groups. Eighteen patients served as controls and underwent evacuation of the haematoma via burr holes and a gravity dependent closed-system drainage. Nineteen patients comprised the study group. These patients had a continuous irrigation-drainage system installed in an attempt to facilitate the removal of fibrinolytic substances present in the haematoma fluid and to try to reduce the rate of rebleeding from the haematoma membranes. No differences were found between the pre- and post-operative clinical status, haematoma volumes and the degree of CT changes between the two groups. The complication rate was similar in the two groups. One patient in the study group and three patients in the control group required an extended period of drainage (24–48 hours) prior to the removal of the drains. All patients improved following the procedures. Within 30 days post the initial evacuation of the chronic subdural haematoma, re-operation was required in only one patient in the study group as opposed to four of the controls. This difference was not however statistically significant. When the need for re-operation was combined with the need for extended drainage period, a significant difference was shown in favour of the study group. These results indicate that drainage combined with continuous irrigation of the subdural space does not affect the clinical outcome of the patients, but significantly reduces the frequency of inadequate drainage of the haematoma and prevents longer drainage periods and repeated operations.     

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.     

Implantation of a reservoir for recurrent subdural hematoma drainage

In a prospective study 144 adult patients with chronic subdural hematomas were randomly divided into three treatment groups after burr-hole evacuation. The two commonly used procedures (external closed system drainage and aspiration and irrigation without any drainage) were compared to a modified technique: permanent subdural drain with subcutaneous reservoir. After the hematoma was washed out with saline solution, a silicon catheter with multiple perforations was introduced into the subdural cavity and connected to a Rickham reservoir, fixed in the frontoparietal burr hole. In patients who showed secondary deterioration or enlargement of the residual hematoma as proven by computed tomographic scan, the reservoir was punctured and the subdural fluid aspirated. The great advantage of this method is that it is practicable at the bedside as well as in the outpatient department, thus making it possible to reduce the number of additional operations. The incidence of symptomatic residual or recurrent hematoma was similar in all three groups. The reoperation rate was 4-fold greater in the groups treated with conventional therapy, when compared to the group with the implanted system. At the same time there was no indication that the implantation of the drain was less safe, as judged by the incidence of seizures and infections.     

Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma

Summary Background. Chronic subdural haematoma is one of the most common entities encountered in daily practice. Many methods of treatment have been reported, each with its own advantages and disadvantages. Method. The authors present a novel technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, we inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma. Findings. We used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%. Conclusions. The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients.     

Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas

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.

Summary

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.

     

Clinical study of reaccumulation and persistence of chronic subdural hematoma; setting an Ommaya reservoir

We treated 57 cases of chronic subdural hematoma by aspiration via the Ommaya reservoir following burr hole opening and irrigation of the hematoma in order to reduce the reaccumulation and persistence of the hematoma. An Ommaya reservoir was placed on the following patients: (1) the volume of hematoma was more than 100 ml and/or (2) expansion of the brain after evacuation of the hematoma was poor. However in spite of these techniques there were 6 cases (10.5%) of recurrence and 21 cases (36.8%) with persistence of the hematoma cavity for longer than 2 months after the first operation. The recurrence was due to occlusion of the Ommaya reservoir by massive rebleeding into the hematoma cavity in cases with a large subdural hematoma and/or an immature external membrane. Persistence of the hematoma cavity for longer than 2 months after the first operation was due to minor rebleeding and CSF inflow into the hematoma cavity through the damaged inner membrane in cases of acute onset and/or or coexisting intracranial disease (brain atrophy, cerebral infarction and subdural effusion). The most suitable cases for application of this technique were those with poor expansion of the brain after evacuation of the hematoma, or those with a mature external membrane and a medium-size hematoma.     

Post-traumatic subdural hygroma: diagnostic conditions and therapeutic attitude in Gabon

An excessive collection of cerebrospinal fluid in the subdural space is known as subdural hygroma, or hydroma. By far, the most common cause is severe cranial trauma. The diagnosis can be made by angiography or computer tomography and, with certainly, only by trephine or burr hole evacuation. 11 cases of post-traumatic subdural hygromas, mainly diagnosed during operative interventions, from April 1981 to September 1988, are reported. Most patients had acute forms of hygroma requiring acute surgical intervention. The acuteness could broken down as: coma (medium Glasgow coma scale: 6), lateralizing neurologic signs (4 cases) and temporal lobe herniation signs (7 cases). There were difficulties in obtaining angiographic studies. 10 patients underwent burr hole evacuation. Craniectomy was performed in one case. Time between cranial trauma and surgical intervention varied from 24 hours (6 cases) to 34 days. It appears that the prognosis is related to the extent of primary brain damage and not to the pressure exerted by the (usually) small mass lesion. The authors propose a clinical management of this lesion and hope for improvement in the diagnostic technics available.     

Recurrent subdural hematoma from a pseudoaneurysm at the cortical branch of the middle cerebral artery after mild head injury: case report

A 67-year-old man presented with a case of recurrent subdural hematomas (SDHs) from a pseudoaneurysm at the cortical artery after mild head trauma. He had undergone two episodes of burr hole trephination and evacuation of SDH in a 6-day interval. Review of previous imaging findings and additional cerebral angiography then identified a pseudoaneurysm arising from the precentral branch of the middle cerebral artery. Acute rebleeding suddenly occurred, and the leak point on the cortical artery was completely repaired with a single suture. SDH from pseudoaneurysm after mild head injury is very unusual. The high morbidity and mortality rates necessitate early detection, but the rarity of this type of injury makes detection difficult. If the clinical course is not easily explainable and is worse than the severity of trauma, repeated SDHs occur, or abnormal lesions and/or subarachnoid hemorrhage are identified, computed tomography or magnetic resonance imaging with contrast medium should be performed to identify the underlying cerebrovascular diseases and determine whether cerebral angiography is necessary.     

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.     

Pathogenetic factors in chronic subdural haematoma and causes of recurrence after drainage

Summary The radiological aspect, pathology, treatment and results of 132 subdural haematomas observed in 100 patients, are discussed.The majority of these cases were characterized by a nonhomogenous CT scan picture, resulting from repeated bleeding in a previous subdural haematoma evolving to chronicity, or in a pre-existent subdural hygroma. Taking aspirin may have constituted a predisposing factor in 16% of our patients, whilst coagulation disturbances, including anticoagulant treatment, were observed in another 6%; ethylism was present in 11%. A traumatic origin was ascertained in 80% of the patients.The treatment consisted of burr hole evacuation and drainage in 91.5% of the haematomas, corresponding to 92% of the patients; it was eventually repeated once or twice in some cases. In 6% of the patients, a subduro-peritoneal drainage had to be placed ultimately and in 2%, a membranectomy had to be performed because the haematoma had become nearly completely fibrous. The necessity for repeated evacuation and eventual subduro-peritoneal drainage seems to depend mainly on a slow brain re-expansion in some elderly people, who are actually more frequently referred.Two patients died; one was deeply comatose and another in poor general condition. Morbidity in the 96 remaining patients, 2 being lost to follow-up, was 11%: 5% related to the haematoma or to the causal trauma, and 6% from other concomitant neurological disease. The functional result was satisfactory in 85%.     

Iatrogenic acute subdural hematoma due to drainage catheter

BACKGROUND

Insertion of a catheter for drainage of a cavity is a routine step in many surgical practices. In neurosurgery, catheters are commonly placed in the subdural, subgaleal, or epidural spaces to prevent haematoma formation.

CASE DESCRIPTION

We present three cases of iatrogenic acute subdural hematoma. These were all related to the drainage catheters. In the first case, a subgaleal redivac suction catheter was used after craniotomy for brain abscess. The other two patients had ordinary ventricular catheters placed in the subdural space after burr hole drainage of chronic subdural hematoma. The drainage catheter was removed on postoperative day 5 in the first case and two days after the initial operation in the other two cases. Shortly after the removal of the drains, the conditions of the patients deteriorated rapidly due to the development of acute subdural hematoma.

CONCLUSION

Although they are extremely uncommon, life-threatening complications related to a drainage catheter are a real possibility. Therefore, the procedure should not be taken lightly.     

Life threatening hyponatraemia following evacuation of spontaneous chronic subdural haematoma

We report the case of a 43-year-old woman who developed life threatening hyponatraemia 4 days following burr hole drainage of a spontaneous chronic subdural haematoma (CSDH). Syndrome of inappropriate secretion of antidiuretic hormone was confirmed. This is the first report of delayed life threatening hyponatraemia developing postoperatively in CSDH. The mechanism remains unclear but may involve brain shift on the pituitary stalk following subdural evacuation.     

Acute subdural haematoma in the conscious patient: Outcome with initial non-operative management

Summary We have retrospectively reviewed 23 conscious patients, in whom a CT scan diagnosis of acute subdural haematoma was made, and in whom craniotomy for evacuation was not initially performed. These highly selected patients represent 3% of 837 patients with acute subdural haematoma, presenting over a five year, eight month period to the Institute of Neurological Sciences, in Glasgow (1986–1991). Patients with any other associated intracranial abnormalities, such as cerebral contusions, as shown on CT, were excluded from this report. All patients were followed by serial CT scanning, and neurological assessments.Cerebral atrophy was present in over half of the sample. In 17 of our patients, the acute subdural haematoma resolved spontaneously, without evidence of damage to the underlying brain, as shown by CT or neurological findings. Six subsequently required burr hole drainage of a hypodense liquid subdural haematoma. In each of these patients, haematoma thickness was greater than 10 mm. Haematoma volume was significantly larger (53±6 ml versus 32±2 ml) in the group who came to operation. The mean delay between injury and operation in this group was 15 days.We conclude that certain conscious patients with small acute subdural haematomas, without mass effect on CT, may be safely managed conservatively.     

A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma

Background

The usage of a drain following evacuation of a chronic subdural haematoma (CSDH) is known to reduce recurrence. In this study we aim to compare the clinical outcomes and recurrence rate of utilising two different types of drains (subperiosteal and subdural drain) following drainage of a CSDH.

Methods

Prospective randomised single-centre study analysing 50 patients who underwent CSDH treatment. Two types of drains, subperiosteal (SPD) and subdural (SDD), were utilised on consecutive alternate patients following burr-hole craniostomy, with a total of 25 patients in each group. The drains were left in for 48-h duration and then removed. The modified Rankin Scale (mRS) was used for outcome measurement at 3 and 6?months.

Results

Data analysis was performed by unpaired t test with Welch’s correction. It was observed that none of the patients in either group had haematoma recurrence during a 6-month follow-up, and a significant difference in outcome was noted at 6?months (p?=?0.0118) more than at 3?months (p?=?0.0493) according to the statistical analysis. Postoperative seizure and inadvertent placement of the subdural drain into the brain parenchyma were the two complications noted in this study. Anticoagulant use prior to the surgery did not affect the outcome in either group.

Conclusions

We conclude there was no recurrence of CSDH utilising the SDD and SPD following burr-hole craniostomy. The mRS measurement at the 6-month follow-up was found to be statistically significant, with better outcomes with utilisation of the SPD. The SPD may thus prove to be more beneficial than the SDD in the treatment of CSDH. A multi-centre study with a larger group of patients is recommended to reinforce the results from our study.     

Chronic subdural hematomas: to drain or not to drain?

A consecutive series of 21 adult patients with chronic subdural hematoma was studied in respect to postoperative resolution of subdural collections and clinical improvement after burr hole evacuation without subdural drainage. This series was compared to a previously studied series of patients with chronic subdural hematoma in whom postoperative closed system drainage had been installed. Using the identical protocol for treatment and postoperative follow-up, we obtained identical results with respect to time-related neurological improvement and persistence of subdural collections in the undrained and drained series, except that the steadily progressive clinical improvement during the early postoperative phase (24 hours) in all cases of the drained series was not universal in the undrained cases. Our study suggests that, to avoid the possibility of early postoperative clinical deterioration, burr hole craniostomy and closed system drainage is advisable. We think that subdural drainage is not necessary when the installation of the drainage system seems to be technically difficult, as it may be in cases with considerable perioperative cortical expansion.     

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.     

A case of organized chronic subdural hematoma showing an early recurrence after craniotomy

A 64-year-old man who had undergone single burr hole drainage twice prior to this admission was hospitalized with a recurrent right chronic subdural hematoma. A head CT showed a mixed density subdural hematoma on the right frontotemporoparietal region. Based on the intraoperative findings of the previous surgeries, the hematoma was known to be organized. Therefore, we decided to do a small craniotomy under general anesthesia, and remove the organized subdural hematoma and thick outer membrane while leaving the thickened dura matter intact. The inner membrane was left untouched. One week later, despite adequate decompression, the hematoma recurred with midline shift on head CT. It is likely that the uniquely thick and vascular enriched outer membrane and dura contributed to such an early recurrence. Finally, we performed an extensive craniotomy, removing all the organized hematoma, outer membrane and dura. Again, the inner membrane was left intact. On one year follow-up the patient has been asymptomatic with complete resolution of the subdural hematoma on CT scan. The successful treatment of organized chronic subdural hematoma can be challenging. We strongly recommend an extensive removal of the organized hematoma, outer membrane and excision of the dura mater in order to achieve a successful outcome after failed burr hole evacuation.