Burr Hole Surgery for Drainage of Chronic and Subacute Subdural Hematomas: Low Recurrence Rate in a Single Surgeon Cohort

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.

Download Full-text

Supervised Valsalva Maneuver after Burr Hole Evacuation of Chronic Subdural Hematomas: A Prospective Cohort Study

Journal of Neurotrauma ◽

10.1089/neu.2020.7391 ◽

2020 ◽

Author(s):

Sae-Yeon Won ◽

Daniel Dubinski ◽

Bedjan Behmanesh ◽

Joshua D. Bernstock ◽

Fee Keil ◽

...

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Valsalva Maneuver ◽

Burr Hole ◽

Subdural Hematomas ◽

Burr Hole Evacuation

Download Full-text

Use of Intraoperative Ultrasonography to Improve the Diagnostic Accuracy of Exploratory Burr Holes in Patients with Traumatic Tentorial Herniation

Neurosurgery ◽

10.1227/00006123-198903000-00006 ◽

1989 ◽

Vol 24 (3) ◽

pp. 345-347 ◽

Cited By ~ 12

Author(s):

Brian T. Andrews ◽

Joshua B. Bederson ◽

Lawrence H. Pitts

Keyword(s):

Head Injury ◽

Brain Stem ◽

Ct Scanning ◽

Intraoperative Ultrasonography ◽

Burr Hole ◽

Ultrasound Images ◽

Frontal Pole ◽

Subdural Hematomas ◽

Head Injured ◽

Injured Patients

Abstract Seventeen head-injured patients with signs of brain stem compression at admission underwent emergency bilateral burrhole exploration before computerized tomographic (CT) scanning. After exploration of the epidural and subdural spaces, real-time ultrasonography was performed intraoperatively to identify intraaxial hematomas. Epidural or subdural hematomas were identified surgically in 11 patients (65%) and immediately evacuated through a craniotomy; in 2 patients, bilateral subdural hematomas were removed. Ultrasonography showed no evidence of intracerebral mass lesions in 14 (82%) of the 17 patients, demonstrated extensive contusions of the temporal lobe in 2 patients (prompting partial lobectomy in both cases), and revealed a small intraparenchymal hematoma deep within the dominant hemisphere, which was not removed, in 1 patient. The sensitivity of ultrasound images for identifying intraparenchymal lesions was evaluated postoperatively by CT or autopsy. In 15 patients (88%), the results of ultrasonography were confirmed. In 2 (12%), CT scans showed small but significant lesions at the frontal pole missed by ultrasonography; one patient had a residual subdural hematoma, and the other a small intraparenchymal hemorrhage. These results confirm that patients with clinical evidence of brain stem compression soon after head injury often have extraaxial hematomas that can be readily identified by burr-hole exploration. Although intraparenchymal hematomas are rare immediately after head injury, they can ususally be identified by intraoperative ultrasonography. This simple technique can reduce the risk of missing intractranial hematomas during emergency burr-hole exploration and improve intraoperative decision making in this population of severely head-injured patients.

Download Full-text

Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence

Journal of Neurosurgery ◽

10.3171/jns.2001.95.2.0256 ◽

2001 ◽

Vol 95 (2) ◽

pp. 256-262 ◽

Cited By ~ 166

Author(s):

Hiroshi Nakaguchi ◽

Takeo Tanishima ◽

Norio Yoshimasu

Keyword(s):

Natural History ◽

Recurrence Rate ◽

Postoperative Recurrence ◽

Cranial Base ◽

Intracranial Extension ◽

Content Type ◽

Subdural Hematomas ◽

History Of ◽

Internal Architecture ◽

Fine Print

Object. Factors affecting the postoperative recurrence of chronic subdural hematomas (CSDHs) have not been sufficiently investigated. The authors have attempted to determine features of CSDHs that are associated with a high or low recurrence rate on the basis of the natural history of these lesions and their intracranial extension. Methods. One hundred six patients (82 men and 24 women) harboring 126 CSDHs who were treated at Tokyo Kosei Nenkin Hospital between January 1989 and April 1998 were studied. Types of CSDHs were classified according to hematoma density and internal architecture, and the intracranial extension of the hematomas were investigated. The postoperative recurrence rate was calculated for each factor. Based on the internal architecture and density of each hematoma, the CSDHs were classified into four types, including homogeneous, laminar, separated, and trabecular types. The recurrence rate associated with the separated type was high, whereas that associated with the trabecular type was low. Chronic subdural hematomas are believed to develop initially as the homogeneous type, after which they sometimes progress to the laminar type. A mature CSDH is represented by the separated stage and the hematoma eventually passes through the trabecular stage during absorption. Based on the intracranial extension of each hematoma, CSDHs were classified into three types, including convexity, cranial base, and interhemispheric types. The recurrence rate of cranial base CSDHs was high and that of convexity CSDHs was low. Conclusions. Classification of CSDHs according to the internal architecture and intracranial extension may be useful for predicting the risk of postoperative recurrence.

Download Full-text

Opening the Internal Hematoma Membrane Does Not Alter the Recurrence Rate of Chronic Subdural Hematomas: A Prospective Randomized Trial

World Neurosurgery ◽

10.1016/j.wneu.2016.04.081 ◽

2016 ◽

Vol 92 ◽

pp. 31-36 ◽

Cited By ~ 19

Author(s):

Claudia Unterhofer ◽

Christian F. Freyschlag ◽

Claudius Thomé ◽

Martin Ortler

Keyword(s):

Randomized Trial ◽

Recurrence Rate ◽

Prospective Randomized Trial ◽

Subdural Hematomas

Download Full-text

Risk factors for reoperation after initial burr hole trephination in chronic subdural hematomas

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2015.08.002 ◽

2015 ◽

Vol 138 ◽

pp. 66-71 ◽

Cited By ~ 33

Author(s):

Falko Schwarz ◽

Franz Loos ◽

Pedro Dünisch ◽

Yasser Sakr ◽

Diaa Al Safatli ◽

...

Keyword(s):

Risk Factors ◽

Burr Hole ◽

Subdural Hematomas

Download Full-text

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.

Download Full-text