Twist-drill Drainage Research Articles

P.169 Tissue plasminogen activator in addition to twist drill drainage as a treatment for chronic subdural hematomas – a descriptive analysis

Background: Current literature provides little consensus on universal guidelines for first-line treatment of chronic subdural hematomas (cSDH). However, administration of local tissue plasminogen activator (tPA) may enhance the traditional method of twist drill drainage (TDD). The study aims to explore the efficacy of TDD with and without tPA, at achieving clinically relevant drainage (200mL) and reducing recurrence of cSDH. Methods: A retrospective review of patients (N=34) with cSDH is presented. Patients who received TDD with tPA (n=17) were identified and matched, based primarily on age and hematoma volume, to a control group (n=17), TDD without tPA. Variables of interest include initial hematoma volume, volume drained, length of stay, and recurrence rates. Descriptive analysis was run. Results: Average age for patients was 74.6 with 76% male. Mean drainage volumes for the tPA cohort was 381.6mL and TDD without tPA cohort was 151.3mL. The addition of tPA resulted in drainage volumes nearly double (1.9x) the clinically relevant amount and had low recurrence rates (12.5%). TDD without tPA failed to result in clinically relevant drainage and had a recurrence rate of 52.9%. Average length of stay differed by two days (9.71 tPA; 7.71 control). Conclusions: TDD with tPA was effective at treating cSDH in our population.

Tissue Plasminogen Activator in Addition to Twist Drill Drainage as a Treatment for Chronic Subdural Hematomas – A Descriptive Analysis

Tissue Plasminogen Activator in Addition to Twist Drill Drainage as a Treatment for Chronic Subdural Hematomas – A Descriptive Analysis

P.206 Tissue Plasminogen Activator in Addition to Twist Drill Drainage as a Treatment for Chronic Subdural Hematomas – A Descriptive Analysis

Background: Current literature provides little consensus on universal guidelines for first-line treatment of chronic subdural hematomas (cSDH). However, administration of local tissue plasminogen activator (tPA) may enhance the traditional method of twist drill drainage (TDD). The study aims to explore the efficacy of TDD with and without tPA, at achieving clinically relevant drainage (200mL) and reducing recurrence of cSDH. Methods: A retrospective review of patients (N=34) with cSDH is presented. Patients who received TDD with tPA (n=17) were identified and matched, based primarily on age and hematoma volume, to a control group (n=17), TDD without tPA. Variables of interest include initial hematoma volume, volume drained, length of stay, and recurrence rates. Descriptive analysis was run. Results: Average age for patients was 74.6 with 76% male. Mean drainage volumes for the tPA cohort was 381.6mL and TDD without tPA cohort was 151.3mL. The addition of tPA resulted in drainage volumes nearly double (1.9x) the clinically relevant amount and had low recurrence rates (12.5%). TDD without tPA failed to result in clinically relevant drainage and had a recurrence rate of 52.9%. Average length of stay differed by two days (9.71 tPA; 7.71 control). Conclusions: TDD with tPA was effective at treating cSDH in our population.

Fibrinolytic-Facilitated Chronic Subdural Hematoma Drainage—A Systematic Review

The current treatment options for chronic subdural hematoma (CSDH) include burr hole drainage, twist drill drainage, and craniotomy with or without postoperative catheter drainage. Although generally effective, these treatments have continued to be complicated by recurrence, especially in partially hemolyzed or septated hematomas. Recently, interest in the use of fibrinolytic agents as an adjunct to surgical treatment to address this limitation has been increasing. We conducted a systematic review, focusing on the efficacy and safety profile of fibrinolytic agents and compared the different fibrinolytic agents. The PubMed, EMBASE, CINAHL Plus, and Cochrane Library databases were searched for trials relevant to fibrinolytic administration in the treatment of CSDH. The findings are reported in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The data from 1702 subjects from 6 retrospective observational studies were qualitatively analyzed. In addition, we included 11 case series and reports for discussion. For 1449 patients, the use of urokinase or tissue plasminogen activator improved hematoma drainage and shortened the hospital stay (7.04 days), with an overall hematoma recurrence rate of 1.59%. The incidence of infection, seizure, and intracranial bleeding was 3.18%, 0.80%, and 0.41%, respectively, which compared favorably with previously reported findings for surgical drainage without the use of fibrinolytic agents. The routine use of intrathecal urokinase and tissue plasminogen activator could be a new direction in the management of CSDH. Conclusive clinical evidence is lacking, however, and further prospective controlled studies are warranted to confirm the benefit and safety of this treatment strategy and to identify the optimal agent and dosing regimen.

A rare asymptomatic retroperitoneal endometriotic cyst with mass effect on the inferior vena cava.

The current treatment options for chronic subdural hematoma (CSDH) include burr hole drainage, twist drill drainage, and craniotomy with or without postoperative catheter drainage. Although generally effective, these treatments have continued to be complicated by recurrence, especially in partially hemolyzed or septated hematomas. Recently, interest in the use of fibrinolytic agents as an adjunct to surgical treatment to address this limitation has been increasing. We conducted a systematic review, focusing on the efficacy and safety profile of fibrinolytic agents and compared the different fibrinolytic agents.The PubMed, EMBASE, CINAHL Plus, and Cochrane Library databases were searched for trials relevant to fibrinolytic administration in the treatment of CSDH. The findings are reported in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The data from 1702 subjects from 6 retrospective observational studies were qualitatively analyzed. In addition, we included 11 case series and reports for discussion.For 1449 patients, the use of urokinase or tissue plasminogen activator improved hematoma drainage and shortened the hospital stay (7.04 days), with an overall hematoma recurrence rate of 1.59%. The incidence of infection, seizure, and intracranial bleeding was 3.18%, 0.80%, and 0.41%, respectively, which compared favorably with previously reported findings for surgical drainage without the use of fibrinolytic agents.The routine use of intrathecal urokinase and tissue plasminogen activator could be a new direction in the management of CSDH. Conclusive clinical evidence is lacking, however, and further prospective controlled studies are warranted to confirm the benefit and safety of this treatment strategy and to identify the optimal agent and dosing regimen.

Chronic Subdural Hematoma: A Questionnaire Survey of Management Practice in India and Review of Literature

To identify the current management modalities practiced by neurosurgeons in India for chronic subdural hematoma. A questionnaire was prepared for the survey and sent via e-mail to neurosurgeons. It covered the following aspects of managing chronic subdural hematoma: 1) demographic and institutional details; 2) choice of surgical procedure; 3) surgical adjutants such as placing a subdural drain; 4) pre- and postoperative care; and 5) recurrences and management. Responses obtained were entered in a SPSS data sheet and analyzed. Response rate of the survey was 9.3%. The majority of neurosurgeons (75%) preferred to do burr whole drainage for primary chronic subdural hematoma and also for recurrences. Only one third of routinely placed a subdural drain. Considerable practice variations exist for medical and perioperative management. Bedside twist drill drainage, which is effective and less costly than operative room procedures, has not gained popularity in practice. The present survey points towards the importance of making management guidelines for this common neurosurgical entity.

Bedside Treatment of Chronic Subdural Hematoma: Using Radiographic Characteristics to Revisit the Twist Drill.

Conventional treatment strategies for the management of symptomatic chronic subdural hematoma (cSDH) in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits. The goal of this study was to identify radiographic characteristics on computed tomography scan that might be used to guide surgical decision making in terms of operative versus bedside removal of cSDH. We retrospectively reviewed clinical and radiographic features in patients who underwent bedside twist drill evacuation of a cSDH and those for a cohort of patients who underwent operative intervention via burr holes. We did not identify any clinical features or preoperative imaging characteristics to suggest an advantage of one procedure over the other. Additionally, complete radiographic resolution of cSDH on postoperative imaging is not required to relieve patient symptoms. Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier resumption of anticoagulation treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates.

Chronic Subdural Hematoma Management

To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients. Current management strategies of CSDHs remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques. We searched MEDLINE (PubMed and Ovid), EMBASE, CINAHL, Google scholar, and the Cochrane library from January 1970 through February 2013 for randomized and observational studies reporting one or more outcome following the management of symptomatic patients with CSDH. Independent reviewers evaluated the quality of studies and abstracted the data on the safety and efficacy of percutaneous bedside twist-drill drainage, single or multiple operating room burr holes, craniotomy, corticosteroids as a main or adjuvant therapy, use of drains, irrigation of the hematoma cavity, bed rest, and treatment of recurrences following CSDH management. Mortality, morbidity, cure, and recurrence rates were examined for each management option. Randomized, prospective, retrospective, and overall observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model. A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and the remaining 234 were observational. We included our unpublished single center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR, 0.69; 95% CI, 0.46-1.05; P = 0.09), morbidity (RR, 0.45; 95% CI, 0.2-1.01; P = 0.05), cure (RR, 1.05; 95% CI, 0.98-1.11; P = 0.15), and recurrence rates (RR, 1; 95% CI, 0.66-1.52; P = 0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR, 1.97; 95% CI, 1.54-2.45; P = 0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR, 0.46; 95% CI, 0.27-0.76; P = 0.002). Craniotomy was associated with higher complication rates if considered initially (RR, 1.39; 95% CI, 1.04-1.74; P = 0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR, 0.22; 95% CI, 0.05-0.85; P = 0.003). Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.

In Vivo Imaging of Twist Drill Drainage for Subdural Hematoma: A Clinical Feasibility Study on Electrical Impedance Tomography for Measuring Intracranial Bleeding in Humans

Intracranial bleeding is one of the most severe medical emergencies in neurosurgery. Early detection or diagnosis would largely reduce the rate of disability and mortality, and improve the prognosis of the patients. Electrical Impedance Tomography (EIT) can non-invasively image the internal resistivity distribution within a human body using a ring of external electrodes, and is thus a promising technique to promptly detect the occurrence of intracranial bleedings because blood differs from other brain tissues in resistivity. However, so far there is no experimental study that has determined whether the intracranial resistivity changes in humans could be repeatedly detected and imaged by EIT. Hence, we for the first time attempt to clinically validate this by in vivo imaging the influx and efflux of irrigating fluid (5% dextrose in water, D5W) during the twist-drill drainage operation for the patients with subdural hematoma (SDH). In this study, six patients (four male, two female) with subacute or chronic SDH received the surgical operation in order to evacuate the hematoma around subdural region, and EIT measurements were performed simultaneously on each patient’s head. The results showed that the resistivity significantly increased on the corresponding position of EIT images during the influx of D5W and gradually decreased back to baseline during the efflux. In the quantitative analysis, the average resistivity values demonstrated the similar results and had highly linear correlation (R2 = 0.93±0.06) with the injected D5W volumes, as well as the area of the resistivity gain(R2 = 0.94±0.05). In conclusion, it was clinically validated that intracranial resistivity changes in humans were detectable and quantifiable by the EIT method. After further technical improvements, EIT has the great potential of being a routine neuroimaging tool for early detection of intracranial bleedings.

Modified twist drill technique in the management of chronic sub dural hematoma.

Burr-hole craniostomy is the most efficient and safe choice for surgical drainage of chronic subdural hematoma (CSDH). Although the twist-drill drainage is also relatively safe and time-saving, it carries the risk of inadequate drainage, brain penetration and hematoma formation. Our modified technique helps in avoiding bleeding and brain penetration. The preferred sites for twist drill were the most curved parts on the cranium. Normal drilling at about 90 degree angle was done on the most curved surfaces while it was at about 60 degree angles on flat surface. This angled drilling and the curved guide wire (hooked in the distal blind end of infant feeding tube), helped to guide infant feeding tube in the hematoma cavity. Dura matter was coagulated using insulated wire. There was no procedure related hematoma, brain penetration and mortality in any of the 50 patients managed by the modified technique. Infant feeding tube was properly positioned in all the cases. Burr hole evacuation was done in 7 cases (14%) due to inadequate evacuation of the hematoma after TDC. Our modified technique of twist drill drainage is inexpensive, simple, safe and effective alternative technique in the treatment of CSDH.

Comparing twist-drill drainage with burr hole drainage for chronic subdural hematoma

Objective The surgical management of chronic subdural hematoma (CSDH) is still a controversial issue, and a standard therapy has not been established because of the unclear pathogenic mechanisms in CSDH. The intention of this paper is to find a simple and efficient surgical procedure for CSDH. Methods A retrospective study of 448 patients with CSDH by surgical treatment during 2005 to 2009 was conducted in order to compare the efficiency between two different primary surgical methods, i.e. twist-drill drainage with-out irrigation in Group A ( n=178) and one burr-hole with irrigation in Group B ( n=270). The results were statistically analyzed. Results The reoperation rates in Group A and Group B were 7.9% and 11.9% respectively. The good outcome rate was 88.8% and 75.5%, the complication was 7.9% and 20.7% in Group A and Group B, respectively. Conclusions The burr-hole drainage with irrigation of the hematoma cavity is not beneficial to the outcome and prognosis. Irrigation is not important in the surgical treatment for C S D H. Thus in initial treatment, twist-drill drainage without irrigation of the hematoma cavity is recommended because it is relatively safe, time-saving and cost-effective.

Chronic subdural hematoma in the elderly: not a benign disease

Chronic subdural hematoma (CSDH) is perceived to be a "benign," easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization. The authors conducted a retrospective review of data obtained in a prospectively identified consecutive series of adult patients admitted to their institution between September 2000 and February 2008 and in whom there was a CT diagnosis of CSDH. Survival data were compared to life-table data. Of the 209 cases analyzed, 63% were men and the mean age was 80.6 years (range 65-96 years). Primary surgical interventions performed were bur holes in 21 patients, twist-drill closed-system drainage in 44, and craniotomies in 72. An additional 72 patients were simply observed. Reoperations were recorded in 5 patients-4 who had previously undergone twist-drill drainage and 1 who had previously undergone a bur hole procedure (p = 0.41, chi-square analysis). Thirty-five patients (16.7%) died in hospital, 130 were discharged to rehabilitation or a skilled care facility, and 44 returned home. The follow-up period extended to a maximum of 8.3 years (median 1.45 years). Six-month and 1-year mortality rates were 26.3% and 32%, respectively. In the multivariate analysis (step-wise logistic regression), the sole factor that predicted in-hospital death was neurological status on admission (OR 2.1, p = 0.02, for each step). Following discharge, the median survival in the remaining cohort was 4.4 years. In the Cox proportional hazards model, only age (hazard ratio [HR] 1.06/year, p = 0.02) and discharge to home (HR 0.24, p = 0.01) were related to survival, whereas the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate. Comparison of postdischarge survival and anticipated actuarial survival demonstrated a markedly increased mortality rate in the CSDH group (median survival 4.4 vs 6 years, respectively; HR 1.94, p = 0.0002, log-rank test). This excess mortality rate was also observed at 6 months postdischarge with evidence of normalization only at 1 year. In this first report of the long-term outcome of elderly patients with CSDH the authors observed persistent excess mortality up to 1 year beyond diagnosis. This belies the notion that CSDH is a benign disease and indicates it is a marker of other underlying chronic diseases similar to hip fracture.

Dexamethasone treatment in chronic subdural haematoma

Neurosurgeons are familiar with chronic subdural haematoma (CSH), a well-known clinical entity, which is usually treated by some modality of trepanation. Despite the excellent outcomes obtained by surgery, complications may occur, some of which may be potentially severe or fatal. Furthermore, up to 25% recurrence rate is reported. The authors present a novel approach to the management of CSH based on the use of dexamethasone as the treatment of choice in the majority of cases. Medical records of 122 CSH patients were retrospectively reviewed. At admission, symptomatic patients were classified according to the Markwalder Grading Score (MGS). Those scoring MGS 1-2 were assigned to the Dexamethasone protocol (4 mg every 8h, re-evaluation after 48-72 h, slow tapering), and those scoring MGS 3-4 were, in general, assigned to the Surgical protocol (single frontal twistdrill drainage to a closed system, without irrigation). Patients were followed in the Outpatient Office with neurological assessment and serial CT scans. RESULTS. Between March 2001 and May 2006, 122 consecutive CSH patients (69% male, median aged of 78, range 25-97) were treated. Seventy-three percent of the patients exhibited some kind of neurological defect (MGS 2-3-4). Asymptomatic patients (MGS 0) were left untreated. Initial treatment assignment was: 101 dexamethasone, 15 subdural drain, 4 craneotomy and 2 untreated. Twenty-two patients on dexamethasone ultimately required surgical drain (21.8%). Favourable outcome (MGS 0-1-2) was obtained in 96% and 93.9% of those treated with dexamethasone and surgical drain, respectively. Median hospital stay was 6 days (range 1- 41) for the dexamethasone group and the whole series, and 8 days (range 5-48) for the surgical group. Overall mortality rate was 0.8% and re-admissions related to the haematoma reached 14.7% (all maintained or improved their MGS). Medical complications occurred in 34 patients (27.8%), mainly mild hyperglycemic impairments. Median outpatient follow up was 25 weeks (range 8-90), and two patients were lost. The rationale for the use of dexamethasone in CSH lies in its anti-angiogenic properties over the subdural clot membrane, as it is derived from experimental studies and the very few clinical observations published. Surgical evacuation of CSH is known to achieve excellent results but no well-designed trials compare medical versus surgical therapies. The experience obtained from this series lets us formulate some clinical considerations: dexamethasone is a feasible treatment that positively compares to surgical drain (and avoided two thirds of operations); the natural history of CSH allows a 48-72 h dexamethasone trial without putting the patient at risk of irreversible deterioration; eliminates all morbidity related to surgery and recurrences; does not provoke significant morbidity itself; reduces hospital stay; does not preclude ulterior surgical procedures; it is well tolerated and understood by the patient and relatives and it probably reduces costs. The authors propose a protocol that does not intend to substitute surgery but to offer a safe and effective alternative. Data obtained from this large retrospective series suggests that dexamethasone is a feasible and safe option in the management of CSH. In the author's experience dexamethasone was able to cure or improve two thirds of the patients. This fact should be confirmed by others in the future. The true effectiveness of the therapy as compared to surgical treatment could be ideally tested in a prospective randomized trial.

Persistent absence of ring-enhancement on CT with an encapsulated brain abscess

Ring-enhancement on CT (RECT) is generally considered a sine qua non in diagnosing a cerebral abscess. We describe a 16-year-old female who presented with headaches, vomiting and drowsiness, which over 2 weeks rapidly progressed to coma. CT demonstrated a moderately large left frontal extradural abscess, associated with contiguous left frontal osteomyelitis, and underlying frontal and ethmoidal sinusitis. In addition, there was a large circular low density area within the left frontal lobe associated with midline shift that, owing to negative RECT, was assumed to represent nascent ischaemic cerebritis. Despite emergency twist-drill drainage of the extradural abscess, and antibiotic/corticosteroids administration, her clinical condition continued to deteriorate and two episodes of uncal herniation were reversed medically. Repeated CT, however, continued to demonstrate negative enhancement within the left frontal low density, although significant enhancement continued to be apparent with recurrent contiguous extradural suppuration. At definitive craniotomy, a large, well-encapsulated abscess cavity was excised from the left frontal lobe corresponding precisely to the area of previously negative enhancement, along with drainage of the recurrent extradural abscess. Thus, in addition to well-known 'false-positives' for RECT with a cerebral abscess, our case highlights the rare occurrence of a 'false-negative'. A low density mass lesion on CT with persistent negative RECT can neither be assumed to represent early cerebritis nor to exclude a mature abscess.

Burr-hole versus twist-drill drainage for theevacuation of chronic subdural haematoma:a comparison of clinical results

Background: Most neurosurgeons remove clinically symptomatic subdural haematomata, but the techniques they choose remain controversial. Method: The results from sixty-two patients diagnosed with chronic subdural haematoma were evaluated for technique, postoperative computerized tomography (CT) scan results, and complications. Results: Eleven patients had haematomata evacuated using twist drill plus drain, 37 patients had haematomata evacuated with burr hole only, and 14 patients were evacuated with bur r hole plus drain. Of the patients who underwent twist drill and closed system drainage (CSD), 43% had smaller lesions on CT follow up scans, as compared with 74% of those who underwent the burr hole only procedure, and 65% with burr holes with drains. C linical outcome results showed that 64% of twist drill and CSD patients deteriorated as compared with 16% of those with burr holes only and 7% with burr holes and CSDs. Sixty-four per cent of twist-drill patients required repeat evacuations as compared w ith 11% of those with burr holes only, and 7% with burr holes plus drains. Conclusion: The results at our institution indicate that burr-hole evacuation for chronic subdural haematoma is superior to twist-drill evacuation with respect to clinical outcome s and complications.