Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial)

Abstract BACKGROUND The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes. OBJECTIVE To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD. METHODS Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay. RESULTS Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups. CONCLUSION Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice

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A prospective randomized study of use of drain versus no drain after burr-hole evacuation of chronic subdural hematoma

International Surgery Journal ◽

10.18203/2349-2902.isj20182242 ◽

2018 ◽

Vol 5 (6) ◽

pp. 2301

Author(s):

Dhanapal Pattanam Velappan ◽

Ponnaiyan Natesan Palaniappan ◽

Anbarasi Pandian

Keyword(s):

Recurrence Rate ◽

Subdural Hematoma ◽

Randomized Study ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Prospective Randomized Study ◽

Recurrence Rates ◽

Eligibility Criteria ◽

Subdural Drain ◽

Burr Hole Evacuation

Background: The incidence of chronic subdural hematoma is 1-2 per 100000 per year in the general population. Inserting subdural drain might reduce the recurrence rate but is not commonly practiced. There are few prospective studies to evaluate the effect of subdural drains.Methods: A prospective randomized study to investigate the effect of subdural drains in the on-recurrence rates and clinical outcome following burr-hole drainage of chronic subdural hematoma was undertaken. During the study period, 100 patients with CSDH were assessed for eligibility. Among 100 patients fulfilling the eligibility criteria, 52 were assigned to drain inserted into the subdural space following burr hole drainage and 48 were assigned subdural drain was not inserted following burr hole drainage. The primary end point was recurrence needing re-drainage and to prevent post-operative pneumocephalus up to a period of 6 months from surgery.Results: Recurrence occurred in 1 of 100 patients with a drain, and 9 of 100 patients in without drain group the medical and surgical complications were comparable between the two study groups.Conclusions: Use of a subdural drain after burr-hole evacuation of a chronic subdural hematoma reduces the recurrence rate and is not associated with increased complications.

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Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study

Neurosurgery ◽

10.1093/neuros/nyy366 ◽

2018 ◽

Vol 85 (4) ◽

pp. 486-493 ◽

Cited By ~ 14

Author(s):

Laurence Johann Glancz ◽

Michael Tin Chung Poon ◽

Ian Craig Coulter ◽

Peter John Hutchinson ◽

Angelos Georgiou Kolias ◽

...

Keyword(s):

Cohort Study ◽

Recurrence Rate ◽

Prospective Cohort ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Recurrence Rates ◽

Drain Group ◽

Subdural Drain ◽

Multicenter Prospective Cohort Study ◽

Multicenter Prospective Cohort

Abstract Background Drain insertion following chronic subdural hematoma (CSDH) evacuation improves patient outcomes. Objective To examine whether this is influenced by variation in drain location, positioning or duration of placement. Methods We performed a subgroup analysis of a previously reported multicenter, prospective cohort study of CSDH patients performed between May 2013 and January 2014. Data were analyzed relating drain location (subdural or subgaleal), position (through a frontal or parietal burr hole), and duration of insertion, to outcomes in patients aged >16 yr undergoing burr-hole drainage of primary CSDH. Primary outcomes comprised modified Rankin scale (mRS) at discharge and symptomatic recurrence requiring redrainage within 60 d. Results A total of 577 patients were analyzed. The recurrence rate of 6.7% (12/160) in the frontal subdural drain group was comparable to 8.8% (30/343) in the parietal subdural drain group. Only 44/577 (7.6%) patients underwent subgaleal drain insertion. Recurrence rates were comparable between subdural (7.7%; 41/533) and subgaleal (9.1%; 4/44) groups (P = .95). We found no significant differences in discharge mRS between these groups. Recurrence rates were comparable between patients with postoperative drainage for 1 or 2 d, 6.4% and 8.4%, respectively (P = .44). There was no significant difference in mRS scores between these 2 groups (P = .56). CONCLUSION Drain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification.

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Burr hole craniostomy versus minicraniotomy in chronic subdural hematoma: a comparative cohort study

Acta Neurochirurgica ◽

10.1007/s00701-021-04902-3 ◽

2021 ◽

Author(s):

Shaian Zolfaghari ◽

Jiri Bartek ◽

Isabelle Strom ◽

Felix Djärf ◽

San-San Wong ◽

...

Keyword(s):

Cohort Study ◽

Recurrence Rate ◽

Subdural Hematoma ◽

Surgical Techniques ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Medical Complications ◽

Recurrence Rates ◽

Significant Difference ◽

Comparative Cohort Study

Abstract Background Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. In surgical management of CSDH, there is a lack of standardized guidelines concerning surgical techniques and a lack of consensus on which technique(s) are optimal. Neurosurgical centers have shown a wide variation in surgical techniques. The purpose of this study was to compare two different surgical techniques, one burr hole craniostomy with an active subgaleal drain (BHC) and minicraniotomy with a passive subdural drain (MC). Methods We conducted a multicenter retrospective cohort study at two neurosurgical centers in Sweden which included patients with unilateral CSDHs that received surgical treatment with either BHC or MC. The primary outcomes in comparison of the techniques were 30-day mortality, recurrence rate, and complications according to the Landriel Ibañez grading system for complications. Results A total of 1003 patients were included in this study. The BHC subgroup included 560 patients, and the MC subgroup included 443 patients. A 30-day mortality when comparing BHC (2.3%) and MC (2.7%) was similar (p = 0.701). Comparing recurrence rate for BHC (8.9%) and MC (10.8%) showed no significant difference (p = 0.336). We found that medical complications were significantly more common in the MC group (p = 0.001). Surgical complications (type IIb) was also associated with the MC group (n = 10, p = 0.003). Out of the 10 patients with type IIb complications in the MC group, 8 had postoperative acute subdural hematomas. Conclusions BHC was comparable to MC concerning 30-day mortality rate and recurrence rates. We did, however, find that MC was significantly associated with medical complications and serious surgical postoperative complications.

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Trephine Craniotomy versus Burr Hole Drainage for Chronic Subdural Hematoma—An Institutional Analysis of 156 Patients

Indian Journal of Neurotrauma ◽

10.1055/s-0040-1713461 ◽

2020 ◽

Vol 17 (02) ◽

pp. 110-120

Author(s):

Ramesh Chandra Vemula ◽

B. C.M. Prasad ◽

Venkat Koyalmantham ◽

Kunal Kumar

Keyword(s):

Ct Scan ◽

Recurrence Rate ◽

Subdural Hematoma ◽

Surgical Intervention ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

P Value ◽

First Choice ◽

Significant Difference ◽

Preoperative Ct

Abstract Introduction Some neurosurgeons believe that doing a trephine craniotomy (TC) decreases the chance of recurrence in chronic subdural hematoma (cSDH). But this is not supported by any evidence. Methods A retrospective analysis of patients who were operated for cSDH from 2014 to 2019 at our institute was done. Factors causing recurrence were studied. Results A total of 156 patients were operated in the given period, among which 88 underwent TC and 68 patients underwent burr hole drainage (BHD) for evacuation of cSDH. All patients underwent two trephines or two burr holes placed according to the maximum thickness of the hematoma. Rate of recurrence in trephine group was 12.5% and in burr-hole group was 11.76% and was not statistically significant. Significant factors for recurrence included nontraumatic cSDH, anticoagulant use, presence of membranes, preoperative computed tomography (CT) showing iso- or mixed-density subdural collection and SDH volume > 60 mL. There was selection bias for the procedure. Patients with subdural membranes were preferentially taken for TC as the percentage of subdural membrane found intraoperatively was significantly greater in trephine group (51.1%) than burr-hole group (17.6%) (p value < 0.001).When all the patients who showed membranes in CT scan were excluded, there was no statistical difference in the base line characteristics of both the groups. After excluding the patients with membranes in preoperative CT scan, there was no significant difference in recurrence rate between the two groups.In TC group with membranes, 8 out of 45 had recurrence, whereas in burr-hole group with membranes, 8 out of 12 had recurrence. This difference was statistically significant. (p value < 0.001). Conclusion Surgical intervention in both modalities improves patient outcome with an overall recurrence rate of 12.17%. In the absence of any identifiable membranes in preoperative CT scan, BHD is the preferred surgical intervention. We prefer TC as first choice for patients with membranes in CT scan.

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The Nelaton Catheter Guard for Safe and Effective Placement of Subdural Drain for Two-Burr-Hole Trephination in Chronic Subdural Hematoma: A Technical Note

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0034-1396435 ◽

2015 ◽

Vol 76 (05) ◽

pp. 415-417 ◽

Cited By ~ 1

Author(s):

Jens Fichtner ◽

Jürgen Beck ◽

A. Raabe ◽

Lennart Stieglitz

Keyword(s):

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Technical Note ◽

Burr Hole ◽

Subdural Drain

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Burr hole craniostomy with novel use of subdural drain for evacuation of chronic subdural hematoma: Case series, literature review, and technical note

Interdisciplinary Neurosurgery ◽

10.1016/j.inat.2019.100501 ◽

2019 ◽

Vol 18 ◽

pp. 100501 ◽

Cited By ~ 1

Author(s):

Vyacheslav Makler ◽

Erin D'Agostino ◽

Stephen J. Guerin ◽

Naser Jaleel

Keyword(s):

Literature Review ◽

Subdural Hematoma ◽

Case Series ◽

Chronic Subdural Hematoma ◽

Technical Note ◽

Burr Hole ◽

Subdural Drain

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The Influence of Postoperative Lesion-Down Head Position on the Recurrence Rate in Chronic Subdural Hematoma after Burr-Hole Surgery

Korean Journal of Neurotrauma ◽

10.13004/kjnt.2012.8.2.134 ◽

2012 ◽

Vol 8 (2) ◽

pp. 134

Author(s):

Gyu-Seong Bae ◽

Seung-Won Choi ◽

Hyon-Jo Kwon ◽

Seon-Hwan Kim ◽

Hyeon-Song Koh ◽

...

Keyword(s):

Recurrence Rate ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Head Position ◽

Burr Hole

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Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

Neurosurgery ◽

10.1227/neu.0000000000001393 ◽

2016 ◽

Vol 79 (5) ◽

pp. 715-721 ◽

Cited By ~ 18

Author(s):

Maria Kamenova ◽

Katharina Lutz ◽

Sabine Schaedelin ◽

Javier Fandino ◽

Luigi Mariani ◽

...

Keyword(s):

Subdural Hematoma ◽

Low Dose ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Recurrence Rates ◽

Dose Aspirin ◽

Low Dose Aspirin

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Drain type after burr-hole drainage of chronic subdural hematoma in geriatric patients: a subanalysis of the cSDH-Drain randomized controlled trial

Neurosurgical FOCUS ◽

10.3171/2020.7.focus20489 ◽

2020 ◽

Vol 49 (4) ◽

pp. E6

Author(s):

Ladina Greuter ◽

Katharina Lutz ◽

Javier Fandino ◽

Luigi Mariani ◽

Raphael Guzman ◽

...

Keyword(s):

Logistic Regression ◽

Clinical Outcome ◽

Elderly Patients ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Recurrence Rates ◽

Patient Age ◽

Post Hoc Analysis ◽

Post Hoc

OBJECTIVEChronic subdural hematoma (cSDH) occurs more frequently in elderly patients, while older patient age is associated with worse postoperative outcome following burr-hole drainage (BHD) of cSDH. The cSDH-Drain trial showed comparable recurrence rates after BHD and placement of either a subperiosteal drain (SPD) or subdural drain (SDD). Additionally, an SPD showed a significantly lower rate of infections as well as iatrogenic parenchymal injuries through drain misplacement. This post hoc analysis aims to compare recurrence rates and clinical outcomes following BHD of cSDH and the placement of SPDs or SDDs in elderly patients.METHODSThe study included 104 patients (47.3%) 80 years of age and older from the 220 patients recruited in the preceding cSDH-Drain trial. SPDs and SDDs were compared with regard to recurrence rate, morbidity, mortality, and clinical outcome. A post hoc analysis using logistic regression, comparing the outcome measurements for patients < 80 and ≥ 80 years old in a univariate analysis and stratified for drain type, was further completed.RESULTSPatients ≥ 80 years of age treated with an SDD showed higher recurrence rates (12.8%) compared with those treated with an SPD (8.2%), without a significant difference (p = 0.46). Significantly higher drain misplacement rates were observed for patients older than 80 years and treated with an SDD compared with an SPD (0% vs 20%, p = 0.01). Comparing patients older than 80 years to younger patients, significantly higher overall mortality (15.4% vs 5.2%, p = 0.012), 30-day mortality (3.8% vs 0%, p = 0.033), and surgical mortality (2.9% vs 1.7%, p = 0.034) rates were observed. Clinical outcome at the 12-month follow-up was significantly worse for patients ≥ 80 years old, and logistic regression showed a significant association of age with outcome, while drain type had no association with outcome.CONCLUSIONSThe initial findings of the cSDH-Drain trial and the findings of this subanalysis suggest that SPD may be warranted in elderly patients. As opposed to drain type, patient age (> 80 years) was significantly associated with worse outcome, as well as higher morbidity and mortality rates.

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