International practice variation in postoperative imaging of chronic subdural hematoma patients

OBJECTIVEThe value of CT scanning after burr hole surgery in chronic subdural hematoma (CSDH) patients is unclear, and practice differs between countries. At the Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, neurosurgeons frequently order routine postoperative CT scans, while the University Medical Center Utrecht (UMCU) in the Netherlands does not have this policy. The aim of this study was to compare the use of postoperative CT scans in CSDH patients between these hospitals and to evaluate whether there are differences in clinical outcomes.METHODSThe authors collected data from both centers for 391 age- and sex-matched CSDH patients treated with burr hole surgery between January 1, 2002, and July 1, 2016, and compared the number of postoperative scans up to 6 weeks after surgery, the need for re-intervention, and postoperative neurological condition.RESULTSBWH patients were postoperatively scanned a median of 4 times (interquartile range [IQR] 2–5), whereas UMCU patients underwent a median of 0 scans (IQR 0–1, p < 0.001). There was no significant difference in the number of re-operations (20 in the BWH vs 27 in the UMCU, p = 0.34). All re-interventions were preceded by clinical decline and no recurrences were detected on scans performed on asymptomatic patients. Patients’ neurological condition was not worse in the UMCU than in the BWH (p = 0.43).CONCLUSIONSWhile BWH patients underwent more scans than UMCU patients, there were no differences in clinical outcomes. The results of this study suggest that there is little benefit to routine scanning in asymptomatic patients who have undergone surgical treatment of uncomplicated CSDH and highlight opportunities to make practice more efficient.

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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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Comparative Study of Surgical Outcome of Chronic Subdural Hematoma Treated with and without External Drainage

Eastern Green Neurosurgery ◽

10.3126/egn.v2i1.27459 ◽

2020 ◽

Vol 2 (1) ◽

pp. 30-34

Author(s):

Suresh Sapkota ◽

Kiran Niraula ◽

Subash Lohani ◽

Shikher Shrestha ◽

Bibhusan Shrestha ◽

...

Keyword(s):

Local Anesthesia ◽

Subdural Hematoma ◽

Surgical Outcome ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Midline Shift ◽

External Drainage ◽

Presenting Symptoms ◽

Number Of Patients ◽

Significant Difference

Background and purpose: Chronic subdural hematoma (cSDH) poses a significant morbidity and mortality risk particularly in elderly population. It can be treated with simple surgical techniques like burr hole drainage under local anesthesia, however it often recurs after surgical evacuation in significant number of patients. Material and methods: A randomized controlled trial was designed at Mayo Hospital/KEMU in 2013 to 2016. Total number of 98 patients who met the inclusion and exclusion criteria were randomized into ‘with drain’ and ‘without drain’ arm. All of them were treated with burr hole drainage under local anesthesia. Half of them had subdural drain while the remaining half did not. Recurrence of hematoma and surgical outcome was compared. Result: Among 98 patients included in the study(54 males and 44 females) met the inclusion criteria. Mean age of presentation was 63 years ± 12.4 (range 40-100). There was left sided preponderance in hematoma location (53.1%). Mean midline shift was 2.7 mm ± 1.5. Owing to drainage of cSDH, post-operative MRC score of patients along with midline shift in the CT brain showed statistically significant improvement. However, irrespective of insertion of drainage system, there was no significant difference noted in recurrence of cSDH, midline shift and improvement in presenting symptoms (hemiparesis or monoparesis) considering all post-operative days. Conclusion: There is no significant difference in recurrence rate depending on weather a postoperative external drainage is placed or not.

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Neurosurgical Aspects of the Parietal Boss in Patients with Chronic Subdural Hematomas

Neurosurgery ◽

10.1227/00006123-198111000-00007 ◽

1981 ◽

Vol 9 (5) ◽

pp. 531-534 ◽

Cited By ~ 4

Author(s):

Takashi Iwabuchi ◽

Tetsuji Sekiya ◽

Tetsuji Sekiya

Keyword(s):

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Ct Scanning ◽

Burr Hole ◽

Computed Tomographic ◽

Subdural Hematomas ◽

Ct Analysis

Abstract There are many modes of trephination for the treatment of chronic subdural hematoma. Angiographic and computed tomographic (CT) analysis of 60 consecutive patients with chronic subdural hematoma indicated that the parietal boss, which is likely to be overlooked by routine CT scanning, is one of the most suitable places for opening a burr hole. Our patients responded satisfactorily to irrigation therapy via a single burr hole in the parietal boss.

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Bedside single burr hole craniostomy drainage of chronic subdural hematoma in the emergency room: A useful option in resource challenged settings

Surgical Neurology International ◽

10.25259/sni_502_2020 ◽

2020 ◽

Vol 11 ◽

pp. 349

Author(s):

Toyin Ayofe Oyemolade ◽

Augustine Abiodun Adeolu

Keyword(s):

Subdural Hematoma ◽

Standard Treatment ◽

Negative Impact ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Emergency Unit ◽

Emergency Ward ◽

Neurological Condition ◽

Accident And Emergency ◽

Neurological Conditions

Background: In resource challenged environments, the standard treatment of chronic subdural hematoma (CSDH) in the theater may be delayed because of the endemic financial constraint and logistic problems with consequent negative impact on the outcome. An emergency bedside burr hole craniostomy with a local anesthetic at the accident and emergency ward may be lifesaving in patients presenting in extreme neurological conditions in these settings. Case Description: We presented three patients (one male and two females) with CSDH who presented at our service in poor neurological condition. The patients were between 49 and 70 years. The Glasgow Coma Score ranged from 3 to 6. The three patients had respiratory and pupillary abnormalities at presentation. They all had bedside single frontal burr hole craniostomy drainage of the hematoma under local anesthesia at the accident and emergency unit of the hospital. Surgery was done within 1 h of review by the neurosurgical team in all cases. The duration of hospital stay ranged from 8 to 24 days. The outcome was good in all cases. Conclusion: Bedside single burr hole craniostomy at the accident and emergency unit may be lifesaving in patients with CSDH who present in extreme neurological condition but in whom prompt standard surgical treatment in the theater is not feasible.

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Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma

Journal of Neurosurgery ◽

10.3171/2016.8.jns16867 ◽

2017 ◽

Vol 127 (5) ◽

pp. 1117-1125 ◽

Cited By ~ 16

Author(s):

Myung-Hoon Han ◽

Je il Ryu ◽

Choong Hyun Kim ◽

Jae Min Kim ◽

Jin Hwan Cheong ◽

...

Keyword(s):

Risk Factors ◽

Clinical Outcomes ◽

Subdural Hematoma ◽

Repeated Measures ◽

Proportional Hazards ◽

Medical Center ◽

Chronic Subdural Hematoma ◽

Cox Proportional Hazards ◽

Risk Factors For Recurrence

OBJECTIVEChronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in elderly patients. Many studies have suggested various factors that may be associated with the recurrence of CSDH. However, the results are inconsistent. The purpose of this study was to determine the associations among patient factors, recurrence, and clinical outcomes of CSDH after bur hole surgery performed during an 11-year period at twin hospitals.METHODSKaplan-Meier analysis was performed to evaluate the risk factors for CSDH recurrence. Univariate and multivariate Cox proportional hazards regression analyses were used to calculate hazard ratios with 95% CIs for CSDH recurrence based on many variables. One-way repeated-measures ANOVA was used to assess the differences in the mean modified Rankin Scale score between categories for each risk factor during each admission and at the last follow-up.RESULTSThis study was a retrospective analysis of 756 consecutive patients with CSDH who underwent bur hole surgery at the Hanyang University Medical Center (Seoul and Guri) between January 1, 2004, and December 31, 2014. During the 6-month follow-up, 104 patients (13.8%) with recurrence after surgery for CSDH were identified. Independent risk factors for recurrence were as follows: age > 75 years (HR 1.72, 95% CI 1.03–2.88; p = 0.039), obesity (body mass index ≥ 25.0 kg/m2), and a bilateral operation.CONCLUSIONSThis study determined the risk factors for recurrence of CSDH and their effects on outcomes. Further studies are needed to account for these observations and to determine their underlying mechanisms.

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A single center's experience with the bedside subdural evacuating port system: a useful alternative to traditional methods for chronic subdural hematoma evacuation

Journal of Neurosurgery ◽

10.3171/2012.11.jns12689 ◽

2013 ◽

Vol 118 (3) ◽

pp. 694-700 ◽

Cited By ~ 15

Author(s):

Mina Safain ◽

Marie Roguski ◽

Alexander Antoniou ◽

Clemens M. Schirmer ◽

Adel M. Malek ◽

...

Keyword(s):

Subdural Hematoma ◽

Medical Center ◽

Chronic Subdural Hematoma ◽

Retrospective Chart Review ◽

Attractive Alternative ◽

Traditional Methods ◽

Presenting Symptoms ◽

Significant Difference ◽

Before And After ◽

Port System

Object The traditional methods for managing symptomatic chronic subdural hematoma (SDH) include evacuation via a bur hole or craniotomy, both with or without drain placement. Because chronic SDH frequently occurs in elderly patients with multiple comorbidities, the bedside approach afforded by the subdural evacuating port system (SEPS) is an attractive alternative method that is performed under local anesthesia and conscious sedation. The goal of this study was to evaluate the radiographic and clinical outcomes of SEPS as compared with traditional methods. Methods A prospectively maintained database of 23 chronic SDHs treated by bur hole or craniotomy and of 23 chronic SDHs treated by SEPS drainage at Tufts Medical Center was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcome was collected. The volume of SDH before and after treatment was semiautomatically measured using imaging software. Results There was no significant difference in initial SDH volume (94.5 cm3 vs 112.6 cm3, respectively; p = 0.25) or final SDH volume (31.9 cm3 vs 28.2 cm3, respectively; p = 0.65) between SEPS drainage and traditional methods. In addition, there was no difference in mortality (4.3% vs 9.1%, respectively; p = 0.61), length of stay (11 days vs 9.1 days, respectively; p = 0.48), or stability of subdural evacuation (94.1% vs 83.3%, respectively; p = 0.60) for the SEPS and traditional groups at an average follow-up of 12 and 15 weeks, respectively. Only 2 of 23 SDHs treated by SEPS required further treatment by bur hole or craniotomy due to inadequate evacuation of subdural blood. Conclusions The SEPS is a safe and effective alternative to traditional methods of evacuation of chronic SDHs and should be considered in patients presenting with a symptomatic chronic SDH.

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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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Efficacy of the direct aspiration-irrigation maneuver for the treatment of chronic subdural hematoma: A single hospital's experience

10.21203/rs.3.rs-273418/v1 ◽

2021 ◽

Author(s):

Zhenjiang Pan ◽

Jing Bao ◽

Shepeng Wei

Keyword(s):

Subdural Hematoma ◽

Chart Review ◽

Chronic Subdural Hematoma ◽

Retrospective Chart Review ◽

Burr Hole ◽

Attractive Alternative ◽

Presenting Symptoms ◽

Significant Difference ◽

Duration Of Surgery ◽

Space Volume

Abstract OBJECTIVE The traditional methods for managing symptomatic chronic subdural hematoma (CSDH) at our hospital include evacuation via single burr-hole irrigation with continuous closed subdural drainage (SBID). The single burr-hole aspiration and irrigation technique with continuous closed subdural drainage (SBAID) is an attractive alternative method. The goal of this study was to evaluate the radiographic and clinical outcomes of SBAID compared with traditional SBID methods. METHODS A database of 51 CSDH patients treated with the SBAID method and 35 CSDH patients treated with the SBID method was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcomes was collected. Predictors of recurrence requiring reoperation and other outcomes were analyzed. RESULTS Compared to the patients in the SBID group, the patients in the SBAID group had a shorter mean duration of surgery (56.6 ± 5.6 minutes vs 59.5 ± 4.8 minutes, respectively, P = 0.02); a shorter mean interval from procedure to discharge (6.2 ± 1.2 days vs 6.8 ± 1.3 days, respectively, P = 0.046); no significant difference in preoperative hematoma volume (106.4 ± 21.7 cm3 vs 101.3 ± 16.3 cm3, respectively, P = 0.25); and a smaller subdural space volume 48 hours after the operation (43.6 ± 7.4 cm3 vs 47.4 ± 9.1 cm3, respectively, P = 0.03).

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Single versus double burr-hole drainage for chronic subdural hematoma: A study of relevant prognostic factors conducted in Pakistan

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.35.4.543 ◽

2019 ◽

Vol 35 (4) ◽

Cited By ~ 1

Author(s):

Habib Ullah Khan ◽

Khaula Atif ◽

Gholamheidar Teimori Boghsani

Keyword(s):

Prognostic Factors ◽

Hospital Stay ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Military Hospital ◽

P Value ◽

Recurrence Rates ◽

Significant Difference ◽

Single Versus

Objective: To compare the efficacy of single versus double burr-hole for drainage of chronic subdural hematoma, keeping in consideration pertinent demographic, pre and postoperative associations. Methods: A prospective cohort study carried out in Combined Military Hospital, Multan, (December 2016-August 2018), on adults with diagnosed chronic subdural hematoma (CSDH); being segregated by randomized control trial, non-probability purposive sampling into Group-A and Group-B (who underwent single and double burr-holes for CSDH-drainage respectively). Utilizing SPSS-21, data expressed as frequencies/percentages and mean± standard deviation (SD) and cross-tabulated; p-value <0.05 was taken as significant. Results: Age and GCS scores were 62±13.694 (range 38-94) and 11.00±3.350 (range 3-15) respectively, males being 40(66.7). Post-operative fatality was Nil, while 8(13.3%) and 14(23.3%) had post-operative seizures and recurrence of hematoma respectively. There was no significant association between type of burr-hole and hospital stay (p 0-884), seizures (p 0.448) or recurrence (p 0.542). Hospital stay (p<0.000) and seizures (p-0.005) were inversely proportional to GCS scores on presentation. Recurrence rates were not affected by age (p-0 .175) or gender (p-0 .281). Conclusion: There was no significant difference between outcomes of single and double burr-hole surgeries; the former must be preferred because of lesser iatrogenic trauma. GCS-score on presentation was validated as a negative association to anticipate post-operative outcomes. doi: https://doi.org/10.12669/pjms.35.4.543 How to cite this:Khan HU, Atif K, Boghsani GT. Single versus double burr-hole drainage for chronic subdural hematoma: A study of relevant prognostic factors conducted in Pakistan. Pak J Med Sci. 2019;35(4):---------. doi: https://doi.org/10.12669/pjms.35.4.543 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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One Versus Double Burr Holes for Treating Chronic Subdural Hematoma Meta-Analysis

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100012956 ◽

2013 ◽

Vol 40 (1) ◽

pp. 56-60 ◽

Cited By ~ 22

Author(s):

Sirajeddin Belkhair ◽

Gwynedd Pickett

Keyword(s):

Subdural Hematoma ◽

Odds Ratio ◽

Revision Rate ◽

Meta Analysis ◽

Random Effect ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Significant Difference ◽

Retrospective Cohort Studies ◽

Burr Holes

Abstract:Objective and Design:There is controversy among neurosurgeons regarding whether double burr hole craniostomy (DBHC) is better than single burr hole craniostomy (SBHC) in the treatment of chronic subdural hematoma (CSH), in terms of having a lower revision rate. In order to compare the revision rates after SBHC versus DBHC, we performed a meta-analysis of the available studies in the literature.Materials and Methods:Multiple electronic health databases were searched to identify all the studies published between 1966 and December 2010 that compared SBHC and DBHC. Data were processed in Review Manager 5.0.18. Effect sizes were expressed in pooled odds ratio (OR) estimates, and due to heterogeneity between studies we used random effect of the inverse variance weighted method to perform the meta-analysis.Results:Five observational retrospective cohort studies were identified: four published studies and one unpublished, describing the outcomes of 355 DBHC and 358 SBHC to evacuate 713 CSH in 631 patients. Meta-analysis showed that there was no significant difference in the revision rates between double burr hole craniostomy and single burr hole craniostomy when performed to evacuate CSH. Pooled odds ratio for all the studies was 0.62 (95% confidence interval 0.26 - 1.46).Conclusions:The results of this meta-analysis suggest that SBHC is as good as DBHC in evacuating chronic subdural hematoma and is not associated with a higher revision rate compared to DBHC.

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