Subperiosteal Drainage versus Subdural Drainage in the Management of Chronic Subdural Hematoma (A Comparative Study)

Introduction: Symptomatic chronic subdural hematomas (CSDH) remain one of the most frequent diagnoses in current neurosurgical practice. Burr-hole craniostomy with irrigation and placement of close-system drainage is the current recommended surgery for symptomatic CSDH. The aim of this study is to perform a direct comparison between two surgical techniques in the treatment of symptomatic CSDH, which have been proven in previous studies to be efficient. Our main objective was to compare the efficacy of placement of a subperiosteal drain (SPD) and a subdural drain (SDD) following single burr-hole craniostomy and irrigation, and to demonstrate any significant differences in terms of overall surgical complications, functional outcome at three months and mortality rate. Materials and Methods: The study was carried out in two local neurosurgical centres. The SPD group was performed in Hospital Umum Sarawak (HUS) and the SDD group was performed in Hospital Sultanah Aminah Johor Bahru (HSAJB), from 1 January 2012 till 30 January 2014 with a total of 30 patients in both treatment groups. Results: Overall, there were no statistically significant difference in terms of patient general characteristics, pre-operative and post-operative symptoms, Markwalder grades, postoperative hematoma volume and recurrence, mortality and functional outcome at discharge and at three month follow-up between both groups. Albeit not achieving statistical significance, we observed a lower rate of surgical complication especially for post-operative intracranial hematoma with placement of the SPD system. Conclusions: Our study concludes that both treatment methods proved to be highly effective in the treatment of CSDH. However, with a lower overall surgical complication rate, treatment with single burr-hole craniostomy, irrigation and placement of the SPD system can be considered a treatment of choice for the management of symptomatic CSDH.

Hematomas subdurales subagudos: ¿solo dos trépanos? / Subacute subdural hematomas: only two drills?

Objetivo: Comparar la evolución postoperatoria de los hematomas subdurales subagudos (HSDSA) y hematomas subdurales crónicos (HSDC) intervenidos con técnica de 2 trépanos, desde junio 2013 a junio 2015. Material y métodos: Se realizó un análisis prospectivo comparando 2 grupos de pacientes: HSDSA y HSDC. Ambos fueron tratados con la misma técnica quirúrgica: dos orificios de trepano, lavado y drenajes subdurales. Se analizaron y compararon: tiempo de cirugía, resolución de los síntomas, necesidad de re-intervención y días de internación. Las variables se presentan como media y DS y mediana y RI, las comparaciones se realizaron con test o Chi2 según su naturaleza, una p <0.05 se considero significativa. Resultados: Fueron evaluados 66 pacientes, 30 HSDSA y 36 HSDC. La edad fue 75 ±11 años (HSDA 76± 11 y HSDC 74 ±12, p 0.5), masculinos 66% (HSDSA 50% y HSDC 85%, p 0.006). El tiempo medio de cirugía para HSDSA fue 59±12 y HSDC 59±17 minutos, p 0.9. Resolvieron la sintomatología en HSDSA 28 (93,3%) y HSDC 34 (94,4%), p 0.8; y requirieron una segunda cirugía por recidiva HSDSA 2 (6,7%) y HSDC 2 (5,6%), p 0.6. La mediana del tiempo de internación fue HSDSA 10 [9- 12] días y HSDC 7,5 [6-10] días, p 0.01. La sobrevida fue del 100%. Conclusiones: La trepanación es una técnica ampliamente aceptada para el tratamiento de HSDC. En hematomas subdurales agudos no existe discusión sobre la necesidad de realizar un abordaje mayor (craneotomía o craniectomía). En el caso de HSDSA la evidencia publicada no es tan concluyente tendiendo en muchos centros a tratarlos en forma similar a los hematomas subdurales agudos generalmente por considerar que la técnica de trepanación y drenaje podría ser insuficiente. Basado en los resultados obtenidos en el presente trabajo podemos concluir que esta técnica es igualmente efectiva para el tratamiento de HSDC y HSDSA y recomendamos su utilización sistemática.

Objective: To compare the postoperative course of subacute subdural hematomas (SSDH) and chronic subdural hematoma (CSDH) operated upon using two burr holes from June 2013 to June 2015. Methods: A prospective analysis was performed comparing patients with SSDH versus CSDH. Both were treated with the same surgical technique —two burr holes— followed by lavage and subdural drainage. Variables compared were surgery time, resolution of symptoms, the need for re-intervention, and number of inpatient days. Variables are presented as means with SD, medians and range, with statistical comparisons performed via Pearson χ2 analysis or XXXXXXXX, as appropriate, with p <0.05 considered significant. Results: A total of 66 patients were analyzed, 30 with SSDH and 36 with CSDH. Mean overall age was 75 ± 11 years with no difference between the two groups (76 ± 11 versus 74 ± 12, respectively; p=0.5). Overall, 66% were male, including 50% with SSDH and 85% with CSDH (p = 0.006). The average lengths of surgery were 59 ± 12 versus 59 ± 17 minutes, respectively (p = 0.9). No intergroup differences were noted in the rate of symptom resolution (93.3% versus 94.4%; p = 0.8) or need for a second surgery for disease recurrence (6.7% vs. 5.6%, p = 0.6). The median length of stay was somewhat shorter in SSDH patients (10 [9-12] vs. 7.5 [6-10] days; p = 0.01). Overall survival was 100%. Conclusions: Trepanation is a widely-accepted technique for the treatment of CSDH. For acute subdural hematomas, there is no discussion regarding the need for a more aggressive approach (e.g., craniotomy or craniectomy). For SSDH, however, published evidence is not as conclusive; yet many centers treat such patients similarly to those with acute subdural hematomas, usually in the belief that trepanation and drainage would be insufficient. Based upon the results obtained in our series, we conclude that this technique is equally effective for the treatment of CSDH and SSDH, and recommend its routine use.

Bilateral Chronic Subdural Hematoma Contaminated with Klebsiella Pneumoniae : An Unusual Case

This article presents the case of a bilateral chronic subdural hematoma which was contaminated with Klebsiella pneumoniae and resulted in a life-threatening central nervous system infection. After repeated of bilateral burr-hole drainage, the patient became hyperpyrexic and drowsy. Suppuration within the subdural space was suspected and then the patient underwent bilateral fronto-temporo-parietal craniotomies, and pus was evacuated. Its cultures revealed Klebsiella pneumoniae. Intravenous meropenem was given for 6 weeks. He recovered completely. Microorganisms like Klebsiella pneumoniae may directly infect the subdural space with iatrogenic contamination.

Cranial subdural hematoma developing after spinal anesthesia: A case report / 대한마취과학회지

Intracranial subdural hematoma is an exceptionally rare complication of spinal anesthesia. An 88-year-old female patient diagnosed with grade V uterine prolapse with rectocystocele received a vaginal hysterectomy and anteroposterior repair under spinal anesthesia. At 4 days postoperatively, she appeared to have decreased orientation, inappropriate behavior, and right side weakness grade III. Brain MR diffusion and CT revealed a bilateral subdural hematoma. She was improved after burr hole drainage. We report a case of intracranial subdural hematoma developing after spinal anesthesia, a rare complication.

Delayed Cerebellar Hemorrhage after Supratentorial Burr-Hole Drainage

We report two cases with delayed cerebellar hemorrhage developed after supratentorial burr-hole drainage, and review the literature. Burr-hole drainage was performed at both sides of bilateral chronic subdural hematomas. The total amount of drainage per day was more than 300ml of hematoma mixed with cerebrospinal fluid(CSF) and the differences in doses between the two sides were significant in both cases. The symptoms improved after drainage but abrupt deterioration of neurological status occurred with the development of cerebellar hemorrhage on postoperative day 4 and 5, in each case. Although both patients were elderly, 75 and 86 years old, they did not have any coagulation defect or episode of severe increase in their blood pressures during drainage. We believe that suprate-ntorial CSF overdrainage can cause cerebellar upward shift, with resultant injury of weakened cerebellar vessels in old age.

Clinical Analysis of Chronic Subdural Hematomas: Review of 69 Operated Cases

The authors analysed retrospectively, 69 cases of chronic subdural hematoma admitted to the Department of Neurological Surgery, from January 1992 to February 1995. All hematomas were operated on by one burr hole trephination and continuous closed-system cather drainage system. The results were as follows: 1) Male was more frequently involved than female with ratio of 5.3:1 and the incidence was prredominent in the patients whose ages were over 50. 2) History of head trauma was found in 52 cases(75.4%), among which habitual alcoholism was found in 6 cases(8.7%). 3) The major symptoms and signs at admission were headache(55.1%), hemiparesis(44.9%), and mental changes(30.4%). 4) On the brain CT scan, hematoma showed low, iso, mixed, and high in density, and the shapes of hematoma were crescenteric, biconvex, planoconvex, and concave in order of frequency. 5) We have found a significant relationship between the neurological grade at admission and the prognosis, and noted full recovery in 45 cases(65.2%) and no d eath as a result of 1-burr hole trephination.

Clinical Study of Chronic Subdural Hematomas

The authors analysed 39 cases chronic subdural hematoma admitted to the Department of Neurosurgery, Seoul Red Cross Hospital from January 1990 to June 1993. The results were as follows : 1) The ratio of male versus female was 6.8 : 1 and the incidence was predominant in patients whose ages were over 50. 2) Past history of head trauma was found in 28 cases(72%) and head trauma with habitual alcoholism was found in 6 cases(15%). 3) Symptoms and signs at admission were headache(90%), hemiparesis(62%), mental change(46%) and vomiting(36%). 4) The densities of hematoma shown in Brain CT scan were iso, hypo, mixed, and hyperdense and the shapes of hematoma were crescenteric, planoconvex, and biconvex in order of frequency. 5) We have found an association between the neurologic grade at admission and the prognosis, and noted full recovery in 33 cases(84%) and no death as a result of the 2-burr hole trephination.

An Analysis of Chronic Subdural Hematoma

The authors analyzed 125 cases with chronic subdural hematoma admitted to the Department of Neurosurgery, Masan Koryo General Hospital from March 1987 until February 1992. The results obtained were as follows. 1) The male to female ratio was 4.9:1 and the incidence was predominant in the patients whose ages were over 50. 2) Antecedent history of head trauma was found in 79 cases(63%). 3) In 70 cases(56%), the density of hematoma shown on CT scan was low. In patients of under 60 years of age, the shape of hematoma was planoconvex, crescent, biconvex in the order of frequency whereas in patients of over 60, the sequence changed to biconvex, crescent, planoconvex. 4) In our series, the patients younger than 60 were managed either with burr hole drainage(40 cases) or craniotomy(34 cases), while the patients older than 60 were treated with burr hole drainage(45 cases) and craniotomy(6 cases). 5) Total mortality rate was 2.4%(3 cases). We have found a significant association between the neurologic grade at admission and prognosis of a patient.

Clinical Analysis of Chronic Subdural Hematoma after Burr-Hole Craniostomy and Closed-System Drainage

In a retrospective study between January 1984, and July 1985, 50 cases of chronic subdural hematoma were analysed. All hematomas were operated on by enlarged burr-hole craniostomy and closed-system drainage. The results of the analysis were summerized as follows: 1) Eighty percent of the patients were 40 years or older. The ratio of male versus female was 4.6:1. 2) History of trauma was present in 70%, Seven patients were known to be chronic alcoholics. 3) The major clinical symptoms and signs were headache(72%), alteration of consciousness(54%), motor weakness(48%), papilledema(34%). 4) Clinical findings at admission and outcome at discharge were graded according to the scale proposed by Markwalder et al. Majority of the patients belonged to group 1(52%), followed by . group 2(40%), 3(6%). 5) The hematoma densities in brain CT at admission were hypodense(46%), isodense(34%), hyperdense(16%), and mixed-dense(4%). The shapes were planoconvex(42%), crescentic(32%), biconvex(26%). Four patients(8%) had bilateral hematomas at admission. 6) The average numbers of burr-hole craniostomy were two (80%), and the average duration of drainage was three days(72%). Only four hematomas were without neomembranes. 7) Burr-hole craniostomy and catheter drainage resulted in an excellent outcome in 43 patients(86%) at the time of discharge. There was no death in this study group.

Clinical Study on Chronic Subdural Hematoma

We have done clinical analysis of 92 cases with chronic subdural hematoma, admitted to our department from August 1, 1984 to July 31, 1987. The following results were obtained; 1) The ratio of male versus female was 3.6:1, and 6 cases(71.7%) were over 50 year-old age. 2) 50 cases(75.7%) in older group(over 50) had head trauma history, and 11 cases(42.3%) in younger group(under 50). 3) The major clinical symptoms and signs in older group were mental deterioration and hemiparesis, in younger group headache and vomiting. 4) The hematoma densities in CT on admission were hyperdense 1.0%, isodense 33.7%, hypodense 39.3%, and mixed 25.9%. The shapes were biconvex 45.7%, planoconvex 35.8%, and crescenteric 18.5%. 5) The operation method was either burr hole drainage, or craniotomy with membranectomy, according to patient's physical condition and CT findings. In postoperative results there was no significant difference in both.

A Clinical Analysis of Traumatic Subdural Hygroma

The authors report a series of 40 cases of traumatic subdural hygroma and discuss the clinical and radiological features, management, surgical results, and pathogenesis. The "simple hygroma" accounted for majority of cases (78%) and among "complex hygroma" cases, subdural hematoma was most often accompanied. Skull fractures was found in 33% of cases. Bilateral subdural hygroma were seen in 67% and delayed onset were noted in 10 cases(25%). Changes in mental status without focal signs of neurologic deficit was noted in over 50% of cases. Although 75% of cases showed full recovery, clinical course marked by persistence of neurologic deficit was noted in 12.5% of cases. Operation was underwent in 72% and simple burr hole drainage was done in most of cases. Reaccumulation rate was relatively high (27.5%) after initial operation. The mortality rate was 12.5.

A Clinical Analysis of Chronic Subdural Hematoma in Aged Person

A series of 41 patients with chronic subdural hematoma, admitted to the Department of Neurosurgery of Catholic Medical College Hospital from May 1, 1980 to May 1, 1984 is presented. The following results were obtained : 1) Male were more frequently involved than female with the ratio of 4.9:1. The over 50 years old age group were predominately 75.6%. 2) The etiologic factors reveal younger group(under 50) has mainly unidentified factors, but older group(over 50) has mainly head trauma history and alcoholism. 3) Older group had more frequently focal neurologic deficit such as hemiplegia, however younger group presented as increased intracranial pressure signs such as headache and vomiting. 4) The hematoma density of C-T scan on admission was hypodense 50%, isodense 30%, mixed 28%, hyperdense 2% and no correlation to age. 5) Younger group performed burr hole with drainage, and older group performed craniotomy with removal of hematoma, but post-operative results were significantly good in older group with craniotomy.

A Clinical Analysis of Chronic Subdural Hematoma with Special Reference to the Follow-up CT-scan and Osmolarity of Hematoma

A series of 70 patients with chronic subdural hematoma, admitted to the Department of Neurosurgery of Kyung Hee University Hospital from Aug. 1, 1977 to July 31, 1982 is presented. The following results were obtained. 1) Males were more frequently involved than female with the ratio of 4.8 : 1. Peak age incidence was 6th and 7th decade. Bilateral subdural collections were only 4 cases and others were unilateral. 2) Older age(more than 50) had more frequently focal neurologic deficit such as hemiplegia, however younger age(less than 50) presented as increased intracranial pressure signs such as headache and vomiting. 3) The hematoma density of CT-scan on admission was hypertense, 3 cases(4.9%); mixed density, 20 cases(32.8%); isodense, 18 cases(29.8%); and hypodense, 20 cases(32.8%) respectively. 4) The operative method between simple burr hole drainage and craniotomy with membranectomy didn't affect the postoperative results. The operative mortality was 2.9%. 5) Follow-up CT scanning was performed in 32 patients, only 8 of them showed normal CT findings within one month after operation. One patient still showed remnant of hematoma on 50th postoperative day. 6) Osmolarities of the hematoma and systemic venous blood were measured simultaneously 10 times in 8 cases. Hematoma osmolarities were isosmolar 1, hyperosmolar 6 and hyposmolar 3 compared with systemic venous blood.