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

Gender-Specific Differences in Chronic Subdural Hematoma

OBJECTIVE

Few studies concerning aspects of gender-specific differences in chronic subdural hematoma (CSDH). This study aimed to determine whether gender-specific differences exist in CSDH regarding clinical, radiological characteristics, and prognosis.

METHODS

A total of 585 patients with CSDH were retrospectively identified. Patients were divided into 2 groups based on gender. Clinical, radiological characteristics, and prognosis were compared using Fisher's exact test or Student t test when applicable. The logistic regression model was used to identify independent risk factors associated with death in CSDH patients. The receiver operating characteristic curve was used to detect the sensitivity and specificity of independent risk factors.

RESULTS

The average age of women was 71.50±0.92 years, significantly older than 67.30±0.60 years in men. Hypertension, diabetes mellitus, and uremia were significantly more common in women than in men. Alcohol intake was more in males than in females. CSDH patients in males manifested homogeneous iso-dense and homogeneous hyper-dense was obviously more than that in the females. Although homogeneous hypo-dense and mixed density were significantly more common in the females. The average preoperative hematoma volume of the unilateral CSDH in males was 160.85±3.06 cm3, significantly more than 139.60±5.70 cm3 in females. The mortality of females was 7.4%, higher than 1.7% in males (P=0.004). Female, age, uremia, and recurrence were independent risk factors for death in CSDH patients.

CONCLUSIONS

Gender-specific differences do exist in CSDH. Female, age, uremia, and recurrence were independent risk factors for death in CSDH patients.

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

OBJECTIVE

Chronic 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.

METHODS

A 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.

RESULTS

A 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).

CONCLUSION

This 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.

Subperiosteal versus Subdural Drain After Burr Hole Drainage for Chronic Subdural Hematomas: A Systematic Review and Meta-Analysis

BACKGROUND

The use of drains has been considered to be superior to no drains after burr hole drainage of chronic subdural hematomas (CSDHs). Therefore, routine placement of a subdural drain (SDD) is supported by most neurosurgeons. However, whether the drain location after CSDH burr hole evacuation influences patient outcomes is unclear. Therefore, we compared the efficacy and safety of subperiosteal drains (SPDs) with those of SDDs for patients with CSDHs.

METHODS

Using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, eligible studies reported up to September 2019 were identified through a search of MEDLINE, EMBASE, and Cochrane Central. Pooled estimates, confidence intervals (CIs), and odds ratios (ORs) were calculated for all outcomes.

RESULTS

Ten studies with 3169 patients were included. The use of a SPD after CSDH burr hole drainage resulted in a significant decrease in recurrences compared with the use of a SDD (OR, 0.73; 95% CI, 0.58-0.92; I², 14%; P = 0.007). No significant differences were identified between the SPD and SDD groups in the favorable outcomes (OR, 1.29; 95% CI, 1-1.68; I², 0%; P = 0.05). Adverse event rates, including mortality, seizures, and surgical infection, were not significantly different between the 2 groups. However, the use of SPDs was associated with a lower risk of parenchymal injuries compared with SDDs (OR, 0.29; 95% CI, 0.11-0.76; I², 0%; P = 0.01).

CONCLUSIONS

The results from the present meta-analysis suggest that the use of an SPD is safer and might be more effective than an SDD in the treatment of CSDH. However, more large randomized controlled trials are needed to investigate the use of SPDs in the management of CSDH.

Risk Factors for Contralateral Hematoma Progression after Unilateral Evacuation of Bilateral Chronic Subdural Hematomas

OBJECTIVE

To find risk factors for contralateral hematoma progression (CHP) in bilateral chronic subdural hematomas after initial unilateral evacuation.

METHODS

We retrospectively analyzed 53 patients with bilateral chronic subdural hematomas who underwent unilateral surgical evacuation in our department. Risk factors for CHP were identified by univariate analysis, a P value <0.05 were entered into multivariate logistic regression model and a predictive receiver operating characteristic curve model.

RESULTS

The progression rate was 32.08%, the average progression interval was 2.32 months. The progression rate of the homogeneous hypodense group was significantly higher than that of the other density group (P = 0.017). The limited type of contralateral hematoma had a significantly lower progression rate than that of the widespread type (P = 0.001). Both pre- and postoperative volume of contralateral hematoma were significantly more in the CHP group compared with the contralateral hematoma without progression group (P = 0.031 and P = 0.001, respectively). Of the 4 risk factors, only postoperative volume of contralateral hematoma was an independent risk factor in multivariate logistic regression model (P = 0.033; 95% confidence interval, 1.005-1.124). The cut-off values of contralateral hematoma volume before and after operation were 29.27 cm³ and 37.84 cm³, respectively.

CONCLUSIONS

Contralateral hematoma volume after operation is an independent risk predictor for CHP after unilateral evacuation. An additional surgery on contralateral hematoma or medical treatment should be taken into consideration if the volume is >37.84 cm³ in the first cranial computed tomography scan after surgery.

International practice variation in postoperative imaging of chronic subdural hematoma patients

OBJECTIVE

The value of CT scanning after burr hole surgery in chronic subdural hematoma (CSDH) patients is unclear, and practice differs between countries. At the Brigham and Women's Hospital (BWH) in Boston, Massachusetts, neurosurgeons frequently order routine postoperative CT scans, while the University Medical Center Utrecht (UMCU) in the Netherlands does not have this policy. The aim of this study was to compare the use of postoperative CT scans in CSDH patients between these hospitals and to evaluate whether there are differences in clinical outcomes.

METHODS

The authors collected data from both centers for 391 age- and sex-matched CSDH patients treated with burr hole surgery between January 1, 2002, and July 1, 2016, and compared the number of postoperative scans up to 6 weeks after surgery, the need for re-intervention, and postoperative neurological condition.

RESULTS

BWH patients were postoperatively scanned a median of 4 times (interquartile range [IQR] 2-5), whereas UMCU patients underwent a median of 0 scans (IQR 0-1, p < 0.001). There was no significant difference in the number of re-operations (20 in the BWH vs 27 in the UMCU, p = 0.34). All re-interventions were preceded by clinical decline and no recurrences were detected on scans performed on asymptomatic patients. Patients' neurological condition was not worse in the UMCU than in the BWH (p = 0.43).

CONCLUSIONS

While BWH patients underwent more scans than UMCU patients, there were no differences in clinical outcomes. The results of this study suggest that there is little benefit to routine scanning in asymptomatic patients who have undergone surgical treatment of uncomplicated CSDH and highlight opportunities to make practice more efficient.