Single burr hole surgery for acute spontaneous subdural hematoma in the aged: patient reports of three cases

The method of treatment for acute spontaneous subdural hematoma in aged patients is controversial. Three cases of acute spontaneous subdural hematoma in aged patients, treated by single burr hole drainage without irrigation, were reported. The first case, an 80-year-old male was admitted with complaints of headache and stupor without any history of head trauma. CT revealed a left subdural hematoma with mixed density. Intractable facial convulsion occurred three days after admission. Single burr hole drainage was performed to remove the hematoma, and facial convulsion disappeared one week after the surgery. The second case, a 70-year-old male was admitted with complaints of consciousness disturbance without any history of head trauma. CT showed a right subdural hematoma with mixed density. The next day, he recovered consciousness and CT demonstrated shrinkage of the hematoma. However, his consciousness deteriorated again 11 days after admission, and CT revealed progression of the hematoma. We performed single burr hole drainage, and the next day, his neurological condition recovered. The third case, an 84-year-old female was admitted with complaints of consciousness disturbance without any history of head trauma. CT revealed a left subdural hematoma with mixed density. Single burr hole drainage was performed to remove the hematoma. She recovered completely and was discharged and return home 1 month after the surgery. Single burr hole drainage is less invasive than craniotomy. Our three cases indicate that this method may be one of the best methods for aged patients with acute spontaneous subdural hematoma which manifests mixed density in CT.     

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 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.     

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。     

Chronic subdural hematoma secondary to coagulopathy

Eleven cases of chronic subdural hematoma (CSH) secondary to coagulopathy were experienced in our department in the last 5 years. They were classified into 4 groups, I: secondary to diffuse metastatic carcinomatosis of the bone marrow (4 cases), II: malignant hematological disease (acute lymphocytic leukemia and myelodysplastic syndrome 1 case each), III: postreplacement of cardiac valves or vein graft having been treated with anticoagulants (warfarin) (3 cases) and IV: chronic renal failure after having been hemodialyzed (2 cases). The outcomes were all good in group III, and there was one good outcome in group IV. However, death was the outcome in all the other cases. Conservative treatment (mannitol and steroid for 2 weeks) was carried out in 4 cases, all of which improved clinically with diminished hematoma. In 9 cases, surgical treatment was attempted by means of burr hole irrigation of the hematoma. Two of them developed intracerebral hematoma, and one developed acute brain swelling. In conclusion, treatment of CSH secondary to coagulopathy should be selected as follows. 1. Conservative treatment is to be the first choice, if conditions allow it. 2. Surgery can be performed by burr hole irrigation when indicated. Precautions should be taken not to injure the inner membrane of the hematoma or the brain proper, and the need for slow decompression should be kept in mind.     

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 case of infected subdural hematoma due to Campyrobacter fetus

A 20-year-old male presented fever, nausea and headache 1 week after eating uncooked liver. On admission, it was revealed he had suffered a closed head injury 3 months before without unconsciousness. On admission, computed tomography scan showed a left chronic subdural hematoma. Gd-DTPA magnetic resonance images revealed unusual enhancement of the capsule and linear enhancement of the subarachnoid space. The patient underwent burr hole irrigation and drainage. The culture of the hematoma content showed Campylobacter fetus. Therefore, the diagnose was infected subdural hematoma. A drainage operation and administration of antibiotics were effective. Our case suggests that enhanced magnetic resonance images are useful for diagnosis and follow-up of infected subdural hematoma.     

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.     

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.     

Causative factors of recurrence of chronic subdural hematoma

Burr hole opening and irrigation of hematoma is now a widespread simple technique for the treatment of chronic subdural hematoma (CSH). However, recurrence of hematoma has been sometimes experienced after initial treatment. The purpose of this report is to analyze the causative factors in recurrence of the hematoma after the burr hole opening and irrigation. Out of 68 adult cases of CSH treated by burr hole opening and irrigation technique at Toranomon Hospital during the past nine years, 11 cases (16.2%) showed recurrence of symptoms due to reaccumulation of hematoma after the 1st operation. They were compared with non-recurrence cases from the viewpoint of clinical signs, symptoms and course and serial CT findings. But there was no statistically significant difference between them. The causative factors of recurrence of CSH were analyzed and divided into four categories. Type 1 (3 cases): specific promoting factors--Primary intracranial hypotension (2 cases) and anticoagulant therapy (1 case). Type 2 (1 cases): immature timing of operation. Type 3 (4 cases): other causes probably due to operative procedure--Insufficient postoperative external drainage. Type 4 (3 cases): unknown cause. Several authors have reported causative factors of recurrence of CSH so far, but they are still controversial. An additive treatment in the cases involving specific factors, and planning the timing and some procedures of operation are proposed in order to avoid recurrence of CSH.     

多次复发难治性慢性硬膜下血肿21例的原因及治疗

目的　探讨反复复发、两次或两次手术以上难治性慢性硬膜下血肿（chronic subdural hematoma, CSDH）的原因及治疗方法。方法　总结分析21例患者的临床资料,结合有关文献进行相关分析。结果　21例难治性CSDH患者中,血肿钻孔引流手术史2次者15例,3次者4例,4次者2例。治疗前CT/MRI扫描发现明显脑萎缩12例,血肿包膜形成8例,血肿分隔多房5例,血肿机化3例。对5例无血肿分房分隔、包膜明显强化及血肿机化的患者仅再行血肿穿刺冲洗引流术,余16例行骨瓣开颅血肿清除+包膜切除术。术后均给予1~2疗程高压氧治疗。随访3~6个月,症状明显改善或消失,无围手术期死亡。术后3个月CT或MRI检查,5例呈硬膜下积液表现,其中2例有占位效应再次行钻孔引流+高压氧治疗;术后6个月,4例有少量硬膜下积液,较前好转,无新复发病例。结论　高龄脑萎缩、包膜形成、血肿分隔多房、血肿机化为难治性CSDH的主要原因;根据不同原因采用开颅血肿和包膜切除或钻孔冲洗引流术+高压氧等治疗可提高治疗效果。     

慢性硬膜下血肿钻单孔双管引流手术治疗体会

【摘要】〓目的〓探讨慢性硬膜下血肿钻单孔置双管外引流术的疗效。方法〓回顾性分析我院2011年6月~2014年3月收治69例慢性硬膜下血肿患者行钻单孔置双管引流手术治疗后的情况。结果〓58例临床症状体征消失,11例改善,无症状加重及死亡病例。经术后1~7天复查CT提示,69例血肿均大部份减少或基本消失,10例并发颅内血肿腔少量积气、积液,随访3个月全部恢复,无复发病例。结论〓慢性硬膜下血肿选择钻单孔置双管外引流效果良好,并发症较少。     

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.     

Acute epidural hematoma following evacuation of chronic subdural hematoma with continuous closed system drainage]

The authors report a case of acute epidural hematoma occurring after evacuation of chronic subdural hematoma with continuous closed system drainage. Laboratory data of the patient including bleeding time were within normal limits. The cause of the postoperative intracranial hematoma was the rapid surgical decompression of the initial lesion, and we considered that it could be prevented if chronic subdural hematoma was treated using closed system drainage and slow decompression. But acute epidural hematoma occurred after this operative procedure and it was accelerated by evacuation of the chronic subdural hematoma through the drain. An emergent craniotomy and removal of the hematoma was performed, so the patient was discharged from hospital with satisfactory neurological recovery. A careful check of the evacuated hematoma volume is very important, and CT scanning should be immediately performed if postoperative hematoma is suspected.     

Middle meningeal artery embolization for refractory chronic subdural hematoma: 3 case reports

The authors present three cases of refractory chronic subdural hematoma (CSDH) treated by embolization of the middle meningeal artery (MMA) after several unsuccessful drainage procedures. The patients were initially treated by the usual method of burr hole and irrigation of the hematoma. After recurrence, several percutaneous puncture and drainage procedures were unable to prevent re-collection of the hematoma. Then the authors embolized the MMA which was thought to be the feeding artery of the outer membrane of the hematoma cavity. No enlargement of the hematoma was seen after embolization and, gradually, complete resolution of the hematoma was obtained. The outcome of the patients was excellent in all three cases. This new therapeutic approach to recurrent CSDH is discussed.     

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.     

脑膜中动脉栓塞治疗高危复发性慢性硬膜下血肿

目的 观察脑膜中动脉栓塞（MMAE）治疗高危复发性慢性硬膜下血肿（HR-CSDH）的有效性及安全性。方法 回顾性分析12例接受MMAE治疗的HR-CSDH患者,其中10例单侧CSDH、2例双侧CSDH,观察治疗效果及并发症。结果 5例首次诊断HR-CSDH患者于钻孔引流术后次日接受MMAE;4例首次诊断HR-CSDH但未达外科钻孔引流术指征者接受单纯MMAE;3例钻孔引流术后复发HR-CSDH患者中,1例于MMAE后次日接受再次钻孔引流术,2例接受单纯MMAE。MMAE中,共栓塞14支脑膜中动脉（MMA）,均栓塞成功。术后6个月内头部CT显示10例（11侧）CSDH血肿完全吸收,2例（3侧）CSDH血肿厚度缩小>50%,未见血肿增大进展者,均无需进一步外科处理。随访期间临床症状均有不同程度改善甚至消失,未见MMAE相关并发症。结论 MMAE治疗HR-CSDH安全、有效。     

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.     

Relationship of direction of drainage tube and recurrence in chronic subdural hematoma

The favorable effect of burr hole irrigation and closed drainage system has been reported in the treatment of chronic subdural hematoma (CSH). After analyzing the relationship of the direction of the drainage tube and recurrence, we have suggested that the residual air after surgery night be important as one of the factors causing recurrence. The present study included 128 chronic subdural hematomas in 102 patients who had been treated in our institute between January, 1996 and October, 2000. We attempted to place the tip of the external drain at the occipital side within the hematoma cavity between January, 1996 and December, 1998 (occipital drainage group), while we tried to insert the tip of the external drain at the frontal side using an endoscope between January, 1999 and October, 2000 (frontal drainage group). We focused on the residual air on CT, the direction of the drainage, recurrence of the hematoma and the size of the hematoma. Some statistical analyses were conducted using these factors. The recurrence rate was slightly lower in the frontal drainage group than that in occipital drainage group. There was no difference in the residual rate of air immediately after the surgery on CT and the recurrence rate between the 2 groups. However, the interval preceding the recurrence was statistically significantly longer in the frontal drainage group. A higher rate of recurrence was noted for cases in which the volume of hematoma was more than 70 ml. The residual rate of air 1 week after surgery was significantly higher in the recurrent group than in non-recurrent group. In this study, it is demonstrated that a long-standing residual of air after surgery is one of the causes of the recurrence of CSH. We must contrive to reduce the residual air after surgery for the treatment of CSH.     

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.