Procedures For Chronic Subdural Hematoma Research Articles

Intraoperative Irrigation and Risk of Chronic Subdural Hematoma Recurrence.

In most neurosurgical centers, irrigation is an essential part of the surgical procedure for chronic subdural hematoma (CSDH). However, it is unknown whether the volume of irrigation fluid affects the risk of CSDH recurrence. This study aimed to investigate a potential association between the volume of irrigation fluid used during burr hole evacuation of CSDH and the risk of CSDH recurrence. This study is a subanalysis of 2 randomized trials (Drain Time & Drain Time 2) designed to investigate the effect of drainage duration on the recurrence of CSDH. Intraoperative irrigation volume was measured, and patients were followed for 90 days for recurrent CSDH. A total of 525 patients with CSDH were included. There was no significant difference in the volume of irrigation fluid used between patients with recurrence (mean = 938 mL, SD = ±552) and without recurrence (mean = 852 mL, SD = ±454) ( P -value = .15). Patients with recurrent CSDH had larger primary CSDH volumes (mean = 134 cm 3 , SD = ±69) than patients without recurrence (mean = 119 cm 3 , SD = ±58) ( P = .04). Multiple logistic regression analysis revealed no association between irrigation volume and recurrence, also when stratified for hematoma size. There was no significant association between irrigation volume and recurrent CSDH within 90 days in patients undergoing burr hole surgery for CSDH.

Abstract No.: ABS0857: Efficacy and Safety of Mini-craniotomy under Local Anaesthesia as a Less Invasive Procedure for Chronic Subdural Hematoma

Background & Aims:Background: Mini-craniotomy is generally considered a better technique than burr hole drainage for chronic subdural haematoma (CSDH) as there are less chances of recurrence and need for re-surgery . But generally mini craniotomy is performed under general anaesthesia and this is found to be associated with post-operative complication in earlier studies. The same procedure when carried under local anaesthesia is expected to cause less post-operative complicationsParameterGroup 1 (GDT) (n=32)Group 2 (CHT) (n=32)P*Total intraoperative fluid input2567.81±534.67492670.62±698.75890.511Total intraoperative blood loss496.87±221.044512.50±216.64590.776Total intraoperative urine output558.59±353.1316466.56±243.83500.230Haematocrit Baseline30.59±6.150630.08±4.44220.705 End of surgery27.07±4.767527.14±4.68710.958 Δ Haematocrit3.73±5.20673.02±4.76940.572 P#0.0000.000Lactate Baseline2.00±1.46201.64±1.11760.284 End of surgery1.65±1.27661.57±0.96950.777 Δ Lactate0.35±0.49180.06±0.70790.069 P#0.0000.000Total ventilator days3.21±4.75594.50±4.75190.300Total ICU days2.00±4.99623.37±6.07340.346Total hospital days6.50±6.44347.46±6.79170.575GCS at discharge$10.26±4.0846 9.56±4.38400.538GOS at 3 months post discharge^4.21±1.31564.00±1.58670.644Methods:In this retrospective study patients of age 50 years or higher those who underwentmini-craniotomy under general or local anaesthesia were included. Preoperative condition, surgery duration and post-operative complications were obtained from patients’ medical records and comparedResults:Sixty patients were included in the study. Thirty-two of these patients underwent mini-craniotomy under LA and thirty-eight under GA. Improvement was better in patients who underwent the surgery under local anaesthesia than the general anaesthesia group. Postoperative complications like pneumonia and DVT (Deep Venous Thrombosis) were less frequent in local anaesthesia group.Conclusion:Mini-craniotomy performed under local anaesthesia is found to have same efficacy than the same procedure performed under general anaesthesia. It is also found to have less chances of recurrence, reoperation and postoperative complication. So, mini-craniotomy under local anaesthesia can be better alternative for CSDH.

Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age

The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients. We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age. Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill. An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.

Comment on "Evaluation of Recurrence Factors and Gorei-san Administration for Chronic Subdural Hematoma after Percutaneous Subdural Tapping"

We previously reported the recurrence factors and the effect of Gorei-san on chronic subdural hematoma (CSDH) using percutaneous subdural tapping. Herein, we comment on less invasive surgical option and postsurgical administration for CSDH. Many factors for CSDH recurrence have been identified and categorized into four groups, namely: patient background, hematoma character, postsurgical administration, and surgical option. Patient background and hematoma character cannot be intervened for patients’ specific problem. Gorei-san has been reported to prevent CSDH recurrence without adverse events even if administered for elder patients. Gorei-san inhibits aquaporin-4, which is expressed on the outer membrane of chronic subdural hematoma. We have good impression of prevention effect of CSDH recurrence especially for those who started Gorei-san before surgery. Several surgical options for CSDH are reported as follows: burr hole surgery, percutaneous subdural tapping, endovascular embolization of middle meningeal artery, and craniotomy. Although burr hole surgery has been performed worldwide as a standard procedure for CSDH, percutaneous subdural tapping has been developed to realize less invasive surgical option, which allows noninvasive measurement of initial hematoma pressure and eases the perioperative management due to rapid discharge.

Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures.

In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH). The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T(2) (tau-squared), I(2), and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis. Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21-0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21-1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage. Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.

Chronic subdural hematoma—Craniotomy versus burr hole trepanation

The authors present a series of more than 200 surgical procedures for chronic subdural hematoma in a 5-year-period. Clinical presentation and neurosurgical treatment were regarded with a special focus on the surgical technique. Between March 2003 and July 2008, 193 patients (113 male and 80 female, mean age 72.5 yrs [range 26–97 yrs]) suffering from chronic subdural hematoma were retrospectively analyzed. One-hundred-fifty-one craniotomies and 42 burr holes were performed. Forty-two craniotomy patients (27.8%) in contrast to 6 burr hole patients (14.3%) required surgical revision. A craniectomy was performed as an ultima ratio after at least 2 prior evacuations in 3 cases. Chronic subdural hematoma is a disease of the elderly. A craniotomy seems to possess a higher rate of recurrence of the chronic subdural hematoma so that a burr hole evacuation should be preferred. Craniectomy might be a good therapeutic option in complicated recurrent chronic subdural hematomas.

67. Some Consideration about the Operative Procedure for Chronic Subdural Hematoma and our “Skull Trephine Method”

67. Some Consideration about the Operative Procedure for Chronic Subdural Hematoma and our “Skull Trephine Method”