Burr Hole Evacuation Of Hematoma Research Articles

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

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. 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. 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. 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.

Elevated Serum Fibrinogen Degradation Products on Admission Is a Novel Predictive Factor for Recurrence of Chronic Subdural Hematoma

Previous studies reported an association of hematologic parameters, including white blood cells, neutrophil, eosinophils, or coagulation-related factors, with prognosis in cerebrovascular disorders. However, an association of recurrence rate with serum coagulation-related factors (e.g., D-dimer or fibrinogen degradation products [FDP]) in chronic subdural hematoma (CSDH) is unclear. Ninety-two patients who experienced first-time CSDH treated with burr-hole hematoma evacuation were included in this study. Laboratory data on admission were used to divide patients into 2 groups: serum FDP >5 μg/mL or FDP ≤5 μg/mL (within normal range), based on the reference range of our institute. We retrospectively compared the recurrence rate of CSDH within 90 days after the first operation between these groups. Statistical significance was accepted at P < 0.05. Patients with an FDP greater than 5 μg/mL showed a significantly increased recurrence rate compared with those with a normal FDP (≤5 μg/mL; 27.3% vs. 10.2%, respectively; P= 0.03). Patients with an FDP greater than 5 μg/mL also showed a significantly higher recurrence rate within 30 days after the operation (15.2% vs. 3.4%, respectively; P= 0.04), but no difference in the recurrence rate at 31-90 days after the operation (12.1% vs. 6.8%, respectively; P= 0.38). In multivariable analysis, monolayer hematoma (odds ratio, 7.61; P= 0.003) and an FDP >5 μg/mL (odds ratio, 5.04; P= 0.01) were independent predictive factors for recurrence within 90 days. Elevated serum FDP on admission is a novel predictive factor for the recurrence of CSDH. These patients require careful follow-up, and recurrence within 30 days after the first operation should be considered.

The Effectiveness of Subdural Drains Using Urokinase after Burr Hole Evacuation of Subacute Subdural Hematoma in Elderly Patients: A Prelimilary Report.

ObjectiveA subdural drain using urokinase after a burr hole hematoma evacuation was performed for subacute subdural hematoma (SASDH), and its effectiveness and safety in elderly patients were evaluated.MethodsBetween January 2013 and May 2015, subdural drains using urokinase after burr hole hematoma evacuation were performed in 19 elderly patients. The inclusion criteria were as follows: 1) a subdural hematoma occurring between 4 and 20 days after injury; 2) worsening neurological symptoms, from mild to moderate or severe, due to injury during the subacute stage; 3) a mix of solid clots (high-density lighter shadow) and fluid hematoma (low-density darker shadow) on the computed tomography (CT) scan; 4) a score of ≥9 on the Glasgow Coma Scale (GCS) assessed immediately before surgery; and 5) an age of ≥65 years. When the majority of the hematoma was evacuated on the CT, we removed the catheter.ResultsUnder local anesthesia, a catheter was inserted into the hematoma through a burr hole. The mean age of the patients was 73.7 years (range, 65-87 years). The mean preoperative GCS score was 11.2 (range, 10-13), and the mean Glasgow Outcome Scale score for all patients was 5 at discharge. No recurrences of hematomas or surgical complications were observed.ConclusionA subdural drain using urokinase after burr hole hematoma evacuation under local anesthesia is thought to be an effective and safe method of blood clot removal with low morbidity. This surgical method is less invasive for treating elderly patients with SASDH.

Surgery in sitting position in patient with ventriculoperitoneal shunt in situ may be hazardous!

Dear Editor: Complications in sitting position are encountered more often than other surgical positions [1]. Literature search did not reveal any case demonstrating development of an extradural hematoma as a result of surgery in sitting position. We report a case of a 4-year-old female child, weighing 10 kg, admitted in our neurosurgical ward with complaints of headache, vomiting, and difficulty in walking for the last 6 months. A magnetic resonance image scan revealed a contrast enhanced lesion in the pineal region suggestive of pineal tumor. She had earlier undergone endoscopic biopsy removal and a right ventriculoperitoneal shunt surgery. Her medical history was unremarkable, and all preoperative routine investigations were within normal limits. She was scheduled for an elective midline suboccipital craniectomy in sitting position. Following a standard fasting protocol, the child was premedicated with oral atropine 0.4 mg, an hour before surgery. Inside the operation theater routine monitors were attached. General anesthesia was induced with fentanyl 20 mcg and thiopentone 50 mg. To facilitate tracheal intubation with cuffed tube size 5.0, rocuronium 10 mg was administered. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide mixture and intermittent boli of fentanyl 1 mcg/kg and rocuronium 0.1 mg/kg. A double lumen central venous catheter was placed in the right subclavian vein. An arterial line placed in the right dorsalis pedis artery allowed continuous monitoring of blood pressure. The child was placed in sitting position with head supported in a three-pin head rest. A near total excision of the tumor was performed by supracerebellar infratentorial approach. The surgical and anesthetic course lasting approximately 4 h was uneventful. There was no episode of venous air embolism. It was planned to mechanically ventilate the lungs until spontaneous reversal of neuromuscular blockade. The patient was shifted for routine CT scan postoperatively, which revealed a large pneumocephalus (Fig. 1a) along with a high right parietal hematoma measuring 4.8× 1.3 cm (Fig. 1b). However, there was no midline shift and mass effect visible on the scan. A burr hole evacuation of hematoma was performed, and patient was weaned off mechanical ventilation on the second postoperative day. A repeat CT scan revealed resolving pneumocephalus, and no other abnormality. We believe that the ventriculoperitoneal shunt tube in situ may have resulted in such a complication. Excessive drainage of cerebrospinal fluid via the drain could have resulted in intracranial hypotension causing rupture of bridging veins, leading to hematoma formation. H. Prabhakar :G. P. Singh :A. Bindra Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India 110029