Outcome of Chronic Subdural Hematoma Treated with Single Burr Hole Under Local Anesthesia

BACKGROUND: Chronic subdural hematoma (CSDH) is a common condition encountered in daily neurosurgical practice usually affecting the elderly population. Various surgical procedures have been used for the evacuation of hematoma in patients with CSDH. The objective of this paper was to study the postoperative outcome of patients who were operated for CSDH and to describe the easy, safest and effective procedure that can be performed at primary level hospitals.METHODS: Institutional based cross-sectional retrospective study was conducted among patients operated for CSDH from January 1, 2012 to December 31, 2015 at Teklehaymanot General Hospital, a private hospital in Addis Ababa, Ethiopia. Descriptive statistics, using SPSS version 20, was used to determine the postoperative outcomes including hospital stay, complications and recurrence rate.RESULTS: Of the 195 charts reviewed, 70.3% were of males, with M: F ratio of 2.4:1. 68.2% of patients being above the age of 55 years with a mean age at presentation of 57.63. The most common presenting symptom was headache followed by extremity weakness. The diagnosis of CSDH was made with either head CT scan or MRI. Forty one percent of patients had a left side hematoma and 48(24.6%) patients had bilateral CSDH. All patients were operated with a single burr hole evacuation under local anesthesia and postoperative subdural closed system drainage by a single neurosurgeon. The mean hospital stay was 3.68±2.6 days. The postoperative outcome was assessed using the Glasgow Outcome Score, and 95.9% of the patients reported good recovery. Thirteen (6.6%) patients were operated twice for recurrence, and there were four deaths.CONCLUSIONS: Single burr hole craniostomy is an easy, safe and effective technique for the treatment of CSDH.

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National randomized clinical trial on subdural drainage time after chronic subdural hematoma evacuation

Journal of Neurosurgery ◽

10.3171/2021.10.jns211608 ◽

2021 ◽

pp. 1-8

Keyword(s):

Hospital Stay ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Length Of Hospital Stay ◽

Burr Hole ◽

Drainage Time ◽

Postoperative Length ◽

The Mean ◽

Burr Hole Evacuation

OBJECTIVE Placement of a subdural drain reduces recurrence and death after evacuation of chronic subdural hematoma (CSDH), but little is known about optimal drainage duration. In the present national trial, the authors investigated the effect of drainage duration on recurrence and death. METHODS In a randomized controlled trial involving all neurosurgical departments in Denmark, patients treated with single burr hole evacuation of CSDH were randomly assigned to 24 hours or 48 hours of postoperative passive subdural drainage. Follow-up duration was 90 days, and the primary study outcome was recurrent hematoma requiring reoperation. Secondary outcome was death. In addition, complications and length of hospital stay were recorded and analyzed. RESULTS Of the 420 included patients, 212 were assigned 24-hour drainage and 208 were assigned 48-hour drainage. The recurrence rate was 14% in the 24-hour group and 13% in the 48-hour group. Four patients died in the 24-hour group, and 8 patients died in the 48-hour group; this difference was not statistically significant. The ORs (95% CIs) for recurrence and mortality (48 hours vs 24 hours) were 0.94 (0.53–1.66) and 2.07 (0.64–7.85), respectively, in the intention-to-treat analysis. The ORs (95% CIs) for recurrence and mortality per 1-hour increase in drainage time were 1.0005 (0.9770–1.0244) and 1.0046 (0.9564–1.0554), respectively, in the as-treated sensitivity analysis that used the observed drainage times instead of the preassigned treatment groups. The rates of surgical and drain-related complications, postoperative infections, and thromboembolic events were not different between groups. The mean ± SD postoperative length of hospital stay was 7.4 ± 4.3 days for patients who received 24-hour drainage versus 8.4 ± 4.9 days for those who received 48-hour drainage (p = 0.14). The mean ± SD postoperative length of stay in the neurosurgical department was significantly shorter for the 24-hour group (2 ± 0.9 days vs 2.8 ± 1.6 days, p < 0.001). CONCLUSIONS No significant differences in the rates of recurrent hematoma or death during 90-day follow-up were identified between the two groups that randomly received either 24- or 48-hour passive subdural drainage after burr hole evacuation of CSDH.

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Neuroendoscopy-Assisted Evacuation of Chronic Subdural Hematoma with Mixed CT Density Through A Novel Small Bone Flap

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1715121 ◽

2020 ◽

Vol 81 (06) ◽

pp. 549-554

Author(s):

Chuan Jun Huang ◽

Xing Liu ◽

Xiao Ting Zhou ◽

Wei Qian ◽

Chen Hong Li ◽

...

Keyword(s):

Subdural Hematoma ◽

Blood Clot ◽

Chronic Subdural Hematoma ◽

Operation Time ◽

Burr Hole ◽

Bone Flap ◽

Cross Sectional ◽

Burr Hole Evacuation ◽

Ct Density ◽

Small Bone

Abstract Objective Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an increasing incidence and favorable prognosis. Surgery is the standard treatment for CSDH, and bur hole evacuation is the most widely employed technique. However, if mixed computed tomography (CT) density is found, burr hole hematoma evacuation is prone to recurrence. Endoscopic examination of the hematoma cavity provides a novel strategy. Here, we present a modification of burr hole evacuation by using neuroendoscopy through a novel small trapezoid bone flap and assess the advantages and risks of the procedure. Methods Twenty-five patients diagnosed with CSDH of mixed CT density were included in this study. Radiographic, epidemiologic, and clinical data were collected and analyzed. In all procedures the burr hole was replaced by a small trapezoidal cross-sectional bone flap, ∼2 cm in diameter. Neuroendoscopy was employed after the subdural cavity was cleaned and drained. The CSDH cavity was inspected thoroughly. If a blood clot, septa, stretching of cortical vessels, or intraluminal trabecular structures with active bleeding were found, the surgeon aspirated the region with a syringe pipe and/or used bipolar electrocoagulation. Results All 25 patients who received 26 neuroendoscopy-assisted operations achieved favorable clinical outcomes. The recurrence rate was 4%. The average operation time was slightly increased compared with the traditional burr hole evacuation due to the use of the neuroendoscope and eventual subsequent treatment. Conclusion Neuroendoscopy provides excellent illumination and vision when a small bone flap is employed. The main advantages of this technique include the precise treatment of structures which are related with progression and recurrence of CSDH, and the minimally invasive nature of the procedure.

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Burr-Hole Evacuation of Chronic Subdural Hematoma: Biophysically and Evidence-Based Technique Improvement

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_167_18 ◽

2019 ◽

Vol 10 (01) ◽

pp. 113-118 ◽

Cited By ~ 1

Author(s):

Martin Májovský ◽

David Netuka ◽

Vladimír Beneš ◽

Pavel Kučera

Keyword(s):

Recurrence Rate ◽

Local Anesthesia ◽

Subdural Hematoma ◽

Scientific Evidence ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Evidence Based ◽

Rural And Remote Areas ◽

Burr Hole Evacuation ◽

Reoperation Rates

ABSTRACTChronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Despite ongoing efforts, recurrence and reoperation rates after surgical treatment remain high. We synthesize scientific evidence on the treatment of CSDH with biophysical principles and then propose a simple and effective surgical technique aiming to reduce the recurrence rate. Under local anesthesia, one burr hole is placed in the area above the maximum hematoma thickness. One drain is inserted into the dorsal direction to the deepest point of the hematoma cavity, and a second drain is inserted frontally into the highest point. Next, saline is gently instilled to the dorsal drain to eliminate air from the hematoma cavity through the frontal drain. Once saline has filled the frontal drain, the frontal drain is removed. The dorsal drain is left in situ for 48 h, and the pressure within the cavity may be adapted hydrostatically. We implemented evidence-based conclusions of previous studies and modified the classical burr-hole technique to reduce the recurrence rate. As a result, we developed a straightforward surgical procedure that is possible to perform under local anesthesia, suitable for everyday practice in rural and remote areas while working with limited resources. The novelty of this technique is in the purposeful reduction of postoperative pneumocephalus, a known independent factor of recurrence. Subdural air is eliminated during surgery using a two-drain system. Safety and efficacy of the technique need to be evaluated in future clinical trials.

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A Rare Complication of Chronic Subdural Hematoma Evacuation: Brain Stem Hemorrhage: A Case Report

Romanian Neurosurgery ◽

10.2478/romneu-2018-0057 ◽

2018 ◽

Vol 32 (3) ◽

pp. 462-465 ◽

Cited By ~ 1

Author(s):

Ghassen Gader ◽

Mouna Rkhami ◽

Maher Ben Salem ◽

Mohamed Badri ◽

Kamel Bahri ◽

...

Keyword(s):

Brain Stem ◽

Subdural Hematoma ◽

Rare Complication ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Burr Hole ◽

Sudden Increase ◽

Vascular Disruption ◽

Rapid Decompression ◽

Surgical Modality

Abstract Chronic subdural hematoma (CSDH), which commonly affects the elderly, is one of the most frequent, but also benign neurosurgical pathologies. Burr hole drainage is the standard surgical modality for evacuation of a CSDH. This technique is known to be safe, with low morbidity and mortality rates. However, postoperative complications have occasionally been reported. We report the case of a 70-year-old man who presented a fatal brain stem hemorrhage after burr-hole drainage for unilateral chronic subdural hematoma. Asymmetrical and rapid decompression were thought to be leading to vascular disruption or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem bleeding. Therefore, a slow rate of evacuation of chronic subdural hematomas, as well as rigorous postoperative reanimation, are recommended in order to prevent serious complications.

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Chronic Subdural Hematomas: To Drain or Not to Drain?

Neurosurgery ◽

10.1227/00006123-198502000-00010 ◽

1985 ◽

Vol 16 (2) ◽

pp. 185-188 ◽

Cited By ~ 76

Author(s):

Thomas Marc Markwalder ◽

Rolf W. Seiler

Keyword(s):

Clinical Improvement ◽

Closed System ◽

Subdural Hematoma ◽

Drainage System ◽

Chronic Subdural Hematoma ◽

Burr Hole ◽

Postoperative Phase ◽

Consecutive Series ◽

Neurological Improvement ◽

Burr Hole Evacuation

Abstract 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.

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Chronic Subdural Hematoma - A Dilemma to Put Drain

Bangladesh Journal of Neurosurgery ◽

10.3329/bjns.v9i1.42921 ◽

2019 ◽

Vol 9 (1) ◽

pp. 26-32

Author(s):

Md Amir Ali ◽

Md Aminul Islam ◽

RU Chowdhury ◽

Ahmed Mursalin ◽

Md Al Amin Salek ◽

...

Keyword(s):

Closed System ◽

Subdural Hematoma ◽

Drainage System ◽

Chronic Subdural Hematoma ◽

The Elderly ◽

Chronic Subdural Haematoma ◽

Burr Hole ◽

Air Entrapment ◽

Number Of Patients ◽

Group A

Background: A chronic subdural hematoma (CSDH) is a collection of blood and blood breakdown products between the surface of the brain and its outermost covering the dura for more than 21 days. The elderly patients are more likely to develop a subdural hematoma, particularly from trivial trauma. CSDHs have been evacuated by burr holes, twist-drill craniotomies and craniotomies. The treatment of chronic subdural haematoma by burr hole drainage has been performed usually without using a closed drainage system, the problem of intracranial air entrapment still persists and can cause a deterioration in the level of consciousness or seizures in the postoperative period. We wanted to compare the effects of patient with drain and those without drain. Objectives: our study is to compare the clinical outcome of CSDH with or without drain. Methods: This prospective study was carried out at CMH Dhaka from January 2017 to July 2018; total 70 cases were investigated for the effectiveness of subdural drain. Cases were randomly allocated in two groups. Data were collected by specially designed questionnaire and analyzed by SPSS. Results and Observation: 70 patients of CSDH were included in this study out of which 25 underwent burr hole with closed system drainage and 45 underwent burr hole without closed system drainage. They were divided into Group A and B, respectively. Among the total number of patients 14 (20%) had shown recurrence. Out of 14 patients, 12 belong to Group B (86 %) and 2 belong to Group a (14 %). Conclusion: It is concluded that, those with a closed system drainage recurrence rate is significantly lower than with burr-hole evacuation alone. Bang. J Neurosurgery 2019; 9(1): 26-32

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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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