Abstract
BackgroundChronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists.ObjectiveTo identify the potential of ACF irrigation to prevent CSDH recurrence. More specifically, to investigate the perioperative and intraoperative prognostic factors, and to identify controllable ones.MethodsTo examine various prognostic factors, 120 consecutive patients with unilateral CSDH treated with burr-hole drainage between September 2007 and March 2013 were analyzed. Intraoperative irrigation was performed with one of two irrigation solutions: normal saline (NS; n = 60) or ACF (n = 60). All patients were followed-up for at least 6 months postoperatively. We also examined the morphological alternations of the hematoma outer membranes after incubation with different solutions.ResultsEleven patients (9.2%) had recurrence. Nine patients (15%) required additional surgery in the NS group, whereas only 2 patients (3.3%) in the ACF group required additional surgery. Among preoperative and intraoperative data, age (<80 years old, P = .044), thrombocyte (>22.0, P = .037), laterality (right, P = .03), and irrigation solution (ACF, P = .027) were related to smaller recurrence rates by log-rank tests. Only the type of irrigation solution used significantly correlated with recurrence in favor of ACF in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04–0.99; P = .049) and logistic regression models (odds ratio, 0.17, 95% CI: 0.03–0.92; P = .04) using these factors. Histological examinations of the hematoma membranes showed that the membranes incubated with NS were loose and infiltrated by inflammatory cells compared with those incubated with ACF.ConclusionIrrigation with ACF decreased the rate of CSDH recurrence.
Highlights
The type of irrigation solution used significantly correlated with recurrence in favor of Artificial cerebrospinal fluid (ACF) in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04–0.99; P = .049) and logistic regression models using these factors
Histological examinations of the hematoma membranes showed that the membranes incubated with normal saline (NS) were loose and infiltrated by inflammatory cells compared with those incubated with ACF
Chronic subdural hematoma (CSDH), typically associated with neurological deterioration after a mild head trauma in elderly patients, is one of the most common neurosurgical disorders. [1,2] Albeit usually amenable to surgery, CSDH has been reported to have a significantly high recurrence rate, ranging from 5% to 30%. [3,4] various irrigation agents such as 5% dextrose solution (D5W), normal saline (NS), lactated Ringer’s solution (LR), and artificial cerebrospinal fluid (ACF) are commonly used in neurosurgery (Table 1), the role of irrigation solution has not been sufficiently assessed in the treatment of CSDH
Summary
Chronic subdural hematoma (CSDH), typically associated with neurological deterioration after a mild head trauma in elderly patients, is one of the most common neurosurgical disorders. [1,2] Albeit usually amenable to surgery, CSDH has been reported to have a significantly high recurrence rate, ranging from 5% to 30%. [3,4] various irrigation agents such as 5% dextrose solution (D5W), normal saline (NS), lactated Ringer’s solution (LR), and artificial cerebrospinal fluid (ACF) are commonly used in neurosurgery (Table 1), the role of irrigation solution has not been sufficiently assessed in the treatment of CSDH.ACF is used as an irrigation fluid during neurosurgical procedures, because its composition is similar to that of human cerebrospinal fluid (CSF). [5,6] Because of its enhanced brainprotective properties compared with conventional commercial solutions such as D5W [1], NS, [7] or LR [8], it has been used routinely, for example, in more than 1000 Japanese facilities, after being marketed as a 500 mL double bag system (Artcereb, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan). [11,12] ACF attenuates edema around a traumatic wound, minimizes cerebrovascular permeability and cell damage, [9] and achieves faster hemostasis without interrupting normal coagulation, [10] than the other solutions. Chronic subdural hematoma (CSDH), typically associated with neurological deterioration after a mild head trauma in elderly patients, is one of the most common neurosurgical disorders. [3,4] various irrigation agents such as 5% dextrose solution (D5W), normal saline (NS), lactated Ringer’s solution (LR), and artificial cerebrospinal fluid (ACF) are commonly used in neurosurgery (Table 1), the role of irrigation solution has not been sufficiently assessed in the treatment of CSDH. ACF is used as an irrigation fluid during neurosurgical procedures, because its composition is similar to that of human cerebrospinal fluid (CSF). Chronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists
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