Twist Drill Craniostomy Research Articles

Burr-Hole Evacuation of Chronic Subdural Haematoma: A Comparative Study between Evacuation With and Without Drainage

Abstract Background: Chronic Subdural Haematomas (CSDH) are relatively common in the geriatric age group. There are several alternatives for surgical management: Burr-hole evacuation, twist drill craniostomy and craniotomy. The widely performed procedure is burr hole evacuation with drainage. Aim of Study: Evaluation of the surgical treatment of chronic subdural haematomas, we studied two surgical options of CSDH: Burr-hole evacuation with and without drainage. Material and Methods: In this retrospective study, we analyzed patients with chronic subdural haematomas subjected to surgery in our institute. A total of 72 patients were studied: 38 underwent burr-hole evacuation and irrigation with post-operative drainage (Group D) and 30 were operated without drainage (Group ND). Results: There was no case of recurrence in the 6-month post-operative period. The average period of hospitalization, the number of post-operative complications, the incidence of rebleeding and the amount of the expansion of the cerebral cortex did not differ between the two groups. Conclusion: The vital step of CSDH surgery is meticulous irrigation during the operation. To insert a drain or not, is not of great value.

Assessment of Frailty in Predicting Surgical Outcomes in Patients with Chronic Subdural Hematomas: Retrospective Chart Review

The aim of this study is to determine if frailty, defined as modified frailty index (MFI) >2.7, correlated with worse postoperative outcomes in patients with chronic subdural hematomas (CSDHs). We also compare the predictive ability of the MFI with another widely used frailty measure, the Clinical Frailty Scale (CFS). We conducted a retrospective chart review of elderly patients (≥65 years) who underwent a twist-drill craniostomy for the evacuation of CSDH at Hamilton General Hospital, Canada, between 2016 and 2018. The primary outcome was the modified Rankin Scale scores at discharge. Logistic regression analyses and receiver operating characteristic curves were carried out to further analyze the factors that influenced independence and functional improvement at discharge. Frail patients were significantly more dependent at discharge (P < 0.0001) and had a lower rate of functional improvement (P= 0.003). When compared with frailty measured by the MFI, frailty as measured by the CFS had a stronger association with functional independence (odds ratio [OR]: 0.081 [0.031, 0.211] vs. OR: 0.256 [0.124, 0.529]) and functional improvement (OR: 0.272 [0.106, 0.693] vs. OR: 0.406 [0.185,0.889]) on logistic regression analyses. Area under the receiver operating characteristic curve analyses showed that the inclusion of frailty into our predictive models improved accuracy. Elderly patients presenting with CSDH who are frail (MFI >0.27) have significantly worse functional outcomes following twist-drill craniostomies. Therefore assessing frailty in this population is important before managing these patients, and for this purpose the CFS is a superior predictor of postoperative function than the MFI.

A simple and effective modified technique of twist drill craniostomy for bedside drainage and irrigation of chronic subdural hematoma: Technical and clinical study

ObjectiveChronic subdural hematoma (CSDH) is an important health problem observed mostly in elderly population. Here, we aimed to describe and validate a simple modified technique of twist-drill craniostomy (TDC) using easily accessible tools for effective and safe bedside CSDH drainage. MethodsA detailed description of the new modified TDC technique which allows for sequential drainage and irrigation under physiological conditions is provided. Clinical and radiological characteristics as well as surgical results of the patients undergoing this procedure are also presented. ResultsA total of 55 patients (30 M, 25 F) underwent this modified TDC. Mean age was 61.7 ± 12.3 years. Medical comorbidities were common (76.4 %). Subdural hematoma was mostly unilateral (83.6 %). Maximum width of hematoma was 21 ± 4 mm on average (range: 9−38 mm). In total, patients underwent 1.6 ± 0.9 subdural tappings on average (median: 1, range: 1−5). Repeat tappings were performed in 43.6 % of the patients. No mortality, serious morbidity or infectious complications were noted. Pneumocephalus was either absent or minimal in most cases (96.4 %). Mean length of hospital stay was 4.9 ± 4.0 days (median: 3; range: 2−20 days). The clinical outcomes were favorable in 92.7 % of the patients (no craniotomy required and no symptomatic recurrence detected). ConclusionThis modified technique of TDC utilizes easily available tools, yields satisfactory radiological and clinical results, allows repeated tappings even in outpatient settings and can thus be readily applied in every neurosurgical unit across the world. It can be an effective alternative to existing procedures for patients with multiple co-morbidities and/or high anesthesia risk, in emergency conditions and busy neurosurgical centers.

Tips and Pearls in Chronic Subdural Hematoma

Background and Aim: One of the most prevalent neurosurgery conditions is Chronic Subdural Hematoma (CSDH). Among neurosurgeons, there are various CSDH treatment approaches. Methods and Materials/Patients: This is a narrative review examining the various aspects of the CSDH. To provide up-to-date information on CSDH, we concisely reviewed the related articles. All of the relevant articles retrieved from Google Scholar, PubMed, and Medline were reviewed and critically analyzed. We searched for keywords including chronic subdural hematoma, burr hole craniotomy versus craniostomy, middle meningeal artery embolization, conservative therapy versus surgical therapy in CSDH, and recurrence of CSDH in published articles from 1960-2020. Results: CSDH may present with various clinical presentations. Medical symptoms range from general and moderate symptoms (such as headache, tiredness) to severe symptoms (e.g. hemiparesis, coma). A definite trauma history may be obtained in most cases. Contrast-enhanced CT or MRI may help diagnosis. The treatment choice for uncomplicated CSDH is Burr-Hole Craniotomy (BHC). The use of drainage to decrease recurrence rates has been shown to have limited outcomes in most recent studies. Craniotomy is also used for treatment. Only asymptomatic or high-risk operative patients are subjected to non-surgical management. Conclusion: Management of CSDH is still contentious. It is widely agreed that if neurological signs and radiological observations are present, CSDH should be evacuated. Burr-hole craniotomy appears to be the preferred surgical technique because, in most patients, it gives the best treatment outcomes. Several issues are still uncertain, including the proper surgical technique [Burr-hole craniotomy versus Twist Drill Craniostomy (TDC) and craniotomy], the advantage of 2 perforated holes over one, the location of drainage, the impact of irrigation of the hematoma, and the duration of post-operative immobilization.

Prediction Models for Recurrence of Chronic Subdural Hematoma in Patients Underwent Twist-Drill Craniostomy Combined With Urokinase Instillation.

The recurrence of chronic subdural hematoma (CSDH) is high post-treatment. In this study, we aimed to construct individualized models for prediction of the postoperative recurrence of CSDH in patients underwent twist-drill craniostomy combined with urokinase (UK) instillation. In total, 183 patients with CSDH were retrospectively enrolled. In summary, 21 candidate factors were retrieved from past medical records. The least absolute shrinkage and selection operator regression was adopted to reduce the high dimensionality of data. Four predictors: preoperative hematoma volume, encephalatrophy, brain re-expansion, and UK instillation frequency were filtered from the 21 candidate factors using the least absolute shrinkage and selection operator method. Binary logistic regression model was employed to establish preoperative and postoperative prediction models. The preoperative model included preoperative hematoma volume and encephalatrophy whereas the postoperative model included brain re-expansion and UK instillation frequency. The predictive performance of the nomograms was evaluated by the receiver operating characteristic curve and calibration chart. Area under curve of the preoperative and postoperative models were 0.755 (95% confidence interval: 0.690-0.889) and 0.782 (95% confidence interval: 0.720-0.936), respectively, indicating good discrimination ability. The calibration results showed good fitting between the predicted probability and the actual probability. Finally, a decision curve analysis revealed excellent clinical performance of the proposed nomograms. Functionally, the preoperative model was used to identify high-risk patients with CSDH and application of UK, while the postoperative model was applied to guide physician-patients communication during follow-up. These 2 prediction models provide a basis for further clinical and experimental studies.

New tools in percutaneous minimally invasive chronic subdural hematomas evacuation

BackgroundIncidence of chronic subdural hematomas (cSDH) is expected to progressive rise in the next decades. There is no univocal indication of the approach to be used. Furthermore, there is no data about the efficacy of twist drill craniostomy (TDC) in hematomas with membranes. ObjectiveTo describe our modified technique for TDC in patients affected by cSDH with membranes and in treatment with antiplatelets. MethodsWe analyzed a group of 37 patients, affected by cSDH with membrane (type D laminar membrane and type G trabecular membrane according to Nakaguchi classification), treated with mushroom TDC using a modified technique. ResultsAfter surgery the average maximum thickness of the common postoperative liquoral subdural collection decreased from 18.8 to 6.21 mm. We documented one acute subdural hematoma (2.7%), asymptomatic and not treated, and one recurrence of cSDH (2.7%) after 2 months that needed re-intervention with single burr hole. ConclusionsWe presented a modified twist drill technique, characterized by the introduction of an application of a new device that optimizes both surgical results, clinical outcome and surgical procedure time. The presence of membrane type D and G does not affect the efficacy of drainage, that is negatively related to the presence of clots or acute hematoma. This modified technique is safe, fast, effective and represents a valid first line treatment of an unstable and unpredictable pathology such as cSDH. We suggest performing such technique on a larger patients’ cohort to further validate its effectiveness.

Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review.

IntroductionChronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice.Methods A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests.ResultsIn all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA.ConclusionIntracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.

Rapid evacuation of chronic subdural hematoma – A possible traumatic brain injury (TBI)

The chronic subdural hematoma is an entity, which affects mainly the elderly patients. According to literature, the complication rate was up to 22,7%, including recurrence of hematoma, worsening of the neurological status, postoperative delirium, etc. Treating of a chronic subdural hematoma could be conservative and operative, including twist drill craniostomy, single or multiple burr hole drainage, and craniotomy. In the patients who underwent a decompression of the hematoma a postoperative hyperperfusion syndrome could be observed, according to literature up to 51,4%. This syndrome is associated risk of postoperative delirium and neurological deterioration.The hyperperfusion syndrome is also observed in traumatic brain injury. A rapid decompression of a subdural hematoma leads to a brain shifting to the skull bones and thus a traumatic brain injury due to decompression. The development of the hyperperfusion syndrome could be related to the decompression of the subdural hematoma in a rapid fashion.

Bedside Percutaneous Twist Drill Craniostomy of Chronic Subdural Hematoma-A Single-Center Study.

Background Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. Objectives This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC). Patients and Methods A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Statistical Analysis Statistical analysis is done using Epi Info software. Results The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD. Conclusions CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

Efficacy of Trauma Catheter and Mushroom Tip Catheter in Evacuation of Chronic Subdural Hematoma and Complications of Drain Placement.

ObjectiveThe aim of this study was to assess the efficacy and complications of trauma catheter versus mushroom tip catheter placement in the evacuation of chronic subdural hematoma via twist drill craniostomy with closed system drainage.BackgroundChronic subdural hematoma (cSDH) is one of the most frequent neurosurgical pathologies in patients >70 years of age with an estimated incidence of 8.2 per 100,000 people per year. The most common risk factors for cSDH are advanced age, alcohol abuse, seizures, cerebrospinal fluid (CSF) shunts, coagulopathies, blood thinners, and patients at risk for falling. Twist drill craniostomy can be performed at the bedside under local anesthesia, making it an attractive treatment option, especially in poly-morbid patients who are poor surgical candidates. A closed drainage system is placed at the time of surgery to allow continuous drainage and promote postoperative brain expansion. Despite the increasing prevalence, limited literature exists to guide surgical management, particularly in terms of drain management and selection of catheter. MethodsThis is a retrospective review of 205 patients from January 2007 to May 2017 at two-level high volume centers for the evaluation and treatment of cSDH. Inclusion criteria include patients >18 years of age with the radiographic presence of a subdural hematoma for greater than three weeks. All patients were managed with either a trauma catheter or mushroom tip catheter. All patients received computed tomography (CT) of the head without contrast prior to subdural drain placement and within 24 hours after subdural drain removal. Exclusion criteria include patients <18 years of age and patients with depressed skull fractures, vascular malformations, subdural empyema, subdural hygroma, or who initially underwent open craniotomy or burr-hole craniotomy.ResultsDrain efficiency in evacuating the cSDH was assessed using both radiographic and clinical markers. Analysis of 205 patients treated by twist drill craniostomy and the subsequent closed system drainage utilizing either the mushroom tip catheter or trauma catheter revealed that neither catheter was superior in producing a statistically significant change in the maximum thickness of the cSDH (p = 0.35) and midline shift (p = 0.45). Furthermore, when assessing patients clinically via utilization of the Glasgow Coma Scale (GCS), both the trauma catheter and the mushroom catheter did not show a statistically significant difference in improving GCS after the evacuation of the cSDH (p = 0.35). Neither catheter was associated with an increased incidence of hemorrhage with drain placement requiring open surgery (p = 0.12), need for additional drain placement (p = 0.13) or decline in GCS with intervention (p = 0.065).ConclusionAnalysis of the 205 patients treated by twist drill craniostomy with closed system drainage for the evacuation of chronic subdural hematoma utilizing either the mushroom tip or trauma catheters revealed that neither catheter was statistically significant in radiographic or clinical improvement in evacuating cSDH. Furthermore, neither catheter was found to be associated with an increased complication risk.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

BackgroundA large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review.Case presentationA total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery.ConclusionsTASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

Modified bedside twist drill craniostomy for evacuation of chronic subdural haematoma.

IntroductionStandard craniotomy (SC) and burr hole craniostomy (BHC) are regarded as the standard approaches to chronic subdural haematoma (CSDH). Bedside twist drill craniostomy (TDC), performed at the patient’s bedside, was introduced as an alternative to the standard methods. However, clinical and radiological features of patients treated with TDC and BHC/SC have not been compared.AimTo demonstrate the specific features of CSDH that affect the surgeons’ preferences when selecting patients for TDC.Material and methodsA retrospective analysis of 32 patients treated due to CSDH in the year 2017 at a single institution was performed. Baseline radiological characteristics, clinical status at admission, complication rate and clinical outcomes were compared between BHC/SC and TDC.ResultsOf the 32 patients, 5 (15.6%) were treated using TDC and 27 (84.4%) by SC or BHC. The duration of the TDC procedure was significantly shorter than the time of standard therapies (p < 0.01). There were no differences between TDC and BHC/SC in terms of baseline clinical characteristics, including age, gender, head trauma history, diabetes, hypertension, antiplatelet drug use, clinical manifestation and the Glasgow Coma Scale score (all p > 0.05). Patients treated with TDC had a significantly thicker haematoma (TDC vs. BHC/SC: mean 25.3 mm vs. 14.6 mm) (p < 0.01) and demonstrated a smaller midline shift (TDC vs. BHC/SC: mean 0.5 mm vs. 4.0 mm) (p = 0.01) compared to those treated with BHC/SC.ConclusionsTwist drill craniostomy is a more effective method for CSDH evacuation compared to SC and BHC. This procedure is considered as the first line treatment for patients with a thicker and non-septated haematoma, and with a smaller midline shift.

Twist Drill Evacuation of Chronic Subdural Hematoma in Comorbid Patients

Chronic Subdural Hematoma (CSDH) is one of the most common types of intracranial hemorrhage, and the prognosis is good if treated properly. The standard treatment for CSDH is surgical evacuation. Various surgical procedures are used such as burr holes evacuation, twist-drill craniostomy, and craniotomy. Our aim is to evaluate the feasibility and safety of twist dill as a first-choice treatment in evacuation of CSDH in comorbid patients. Methods: This study is a prospective analysis of CSDH evacuation using two twist drill craniostomy holes and irrigation conducted on 21 patients with different comorbidities in Assuit University Hospital between May 2017 and May 2018. Results: The overall postoperative clinical improvement was 95.2%. The operative time was less than 10 minutes in 71.4% of the patients. 4 patients showed residual collection in the post-operative CT (19%). Pneumocephaly was detected in 2 patients (9.5%). Postoperative seizures occurred in 2 patients (9.5%), and subarachnoid hemorrhage was detected in one patient (4.7%). Conclusion: This approach is a new modification of twist drill craniostomy which can decrease the postoperative residual and recurrence rates and also still a minimally invasive and lifesaving technique in patients with different comorbidities.

How to Treat Chronic Subdural Hematoma? Past and Now.

Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.

A Single Institute Five-Year Surgical Experience with Chronic Subdural Hematoma: Analysis of 270 Consecutive Patients at a Tertiary Care Centre

Abstract Chronic subdural hematoma (CSDH) is one of the very common surgically treatable neurosurgical entities. Still there is lack of uniformity in the management of CSDH amongst surgeons in terms of various treatment strategies and protocols. Burrhole drainage is the treatment modality of choice for an uncomplicated CSDH. Some recent trials support the use of drain to lessen the rate of recurrence. Twist drill craniostomy and craniotomy do also play a role in the management of CSDH. The current study is a retrospective analysis of 270 surgically treated patients with chronic subdural hematoma at a tertiary care center over a span of five years. The present study highlighted on rate of recurrence, re-surgery, mortality and morbidity.

Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas.

Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10mm in size or those associated with more than 5-mm midline shift are deemed operative. While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.

Treatment Standards for Chronic Subdural Hematoma: Results from a Survey in Austrian, German, and Swiss Neurosurgical Units

Although an abundance of literature about the treatment of chronic subdural hematoma is available, it provides little evidence to clarify which treatment is most successful. The aim of this study was to examine and compare current clinical standards between several hospitals. Chairmen of all neurosurgical units in Austria, Germany, and Switzerland, as listed on the national neurosurgical societies' websites, were invited to participate with a personal token to access a web-based survey. A total of 159 invitations were sent and up to 5 reminder e-mails. Eighty-four invitees (53%) completed the survey. The most common surgical intervention was a single burr hole in 52 (65%) of the responding neurosurgical units, double burr holes were performed as primary procedure in 16 centers (20%), a small osteoplastic craniotomy in 4 (5%), and a twist drill craniostomy in 8 (10%). Seventy-two (90%) would place a drain in estimated 75%-100% of cases or whenever possible/safe. Sixty-five used subdural-external drains, and 7 used subgaleal-external drains. Seventeen applied suction to the drains. Thirty-six (49%) agreed with the statement that watchful waiting was an option for the treatment of chronic subdural hematomas and 19 (23.4%) disagreed. Eighteen (23%) would consider corticosteroids and 34 (45%) tranexamic acid as part of their armamentarium for the treatment of subdural hematomas. The results of this survey reflect the current evidence available in literature. Although the benefits of using of a drain are widely recognized, no consensus regarding the type of drain and surgical approach to the hematoma was reached.

Complications of Extended Endoscopic Endonasal Surgery in Elderly Patients.

Extended endoscopic endonasal procedures are not unique among surgical interventions in carrying increased risk in the elderly population. There are, however, components of the procedure, namely high-flow cerebrospinal fluid leaks, that do result in the potential for increased perioperative morbidity for these patients. We present the case of a 77-year-old male with a large invasive pituitary macroadenoma resected through a transplanum-transtuberculum-transsellar endonasal approach. A gross total resection was obtained with resolution of the patient's preoperative ophthalmologic deficits. One month postoperatively, the patient developed progressive lethargy and cranial imaging demonstrated a left convexity subacute subdural hematoma. This was evacuated through a twist drill craniostomy. Despite measures to limit the operative time of the initial endonasal procedure as well as the absence of a postoperative cerebrospinal fluid fistula, the patient still developed this complication. Along with more typical potential causes of postoperative decline following extended endonasal procedures, problems from high-flow intraoperative cerebrospinal fluid leaks alone can result in morbidity in the elderly population. This should be acknowledged preoperatively and a high suspicion should exist for the presence of intracranial hemorrhage in these patients with any postoperative deficits. Additional intraoperative measures can be utilized to minimize such risks. The link to the video can be found at: https://youtu.be/EkLmt2T8_UE .

Survey of Available Literature and Meta-Analyses on Chronic Subdural Hematoma

A chronic subdural hematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. It is a common condition, especially in elderly patients, with an incidence of 58 cases per 100,000 people per year in patients over 65 years of age, a mortality rate of about 2%, and a recurrence rate ranging from 11.7% to 28% despite surgical and medical treatments. Due to the high incidence of CSDH, a vast amount of literature exists on the various medical and surgical aspects. Moreover, the literature contained meta-analyses analyzing different techniques, medical therapies, and factors associated with prognoses. Herein, the available literature and meta-analyses on different aspects of CSDH are reviewed in order to provide a rapid review of the best evidence regarding this condition. Twelve meta-analyses comparing the effects of different surgical and/or medical treatments on various different clinical outcomes were analyzed. Strong evidence was found that: 1) burr-hole craniostomy and twist-drill craniostomy are both efficacious in treating CSDH; 2) drainage placement is associated with better clinical outcomes and significantly lower recurrence rates; 3) antithrombotic drugs are significantly associated with a higher recurrence rate; and 4) in case of need of reoperation, open craniotomy is associated with better outcomes compared with minimally invasive procedures. Further studies are needed to clarify the role of corticosteroids and the best timing of the resumption of antithrombotic drugs after CSDH evacuation.