Twist-Drill or Burr Hole Craniostomy for Draining Chronic Subdural Hematomas: How to Choose It for Chronic Subdural Hematoma Drainage

Comparison of Burr-Hole Craniostomy versus Twist-Drill Craniostomy Operations for Patients with Chronic Subdural Hematoma: A Systematic Review and Network Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) represents one of the most common neurologic disorders in the elderly. However, the optimum surgical option remains questionable. This study aims to compare the safety and efficacy of single burr-hole craniostomy (sBHC), double burr-hole craniostomy (dBHC), and twist-drill craniostomy (TDC) in patients with CSDH.

METHODS

We searched PubMed, Embase, Scopus, Cochrane, and Web of Science until October 2022 for prospective trials. Primary outcomes comprised recurrence and mortality. The analysis was performed using R software, and the results were reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Data from 11 prospective clinical trials were included in this network meta-analysis. We found that dBHC significantly decreased recurrence and reoperation rates compared with TDC (RR = 0.55, CI, 0.33-0.90 and RR = 0.48, CI, 0.24-0.94, respectively). However, sBHC showed no difference compared with dBHC and TDC. There was no significant difference among dBHC, sBHC, and TDC regarding the hospitalization duration, complication rates, mortality, and cured rates.

CONCLUSIONS

dBHC seems to be the best modality for CSDH compared with sBHC and TDC. It showed significantly less recurrence and reoperation rates compared with TDC. On the other hand, dBHC showed no significant difference with the other comparators regarding complication, mortality, and cure rates in addition to the hospitalization duration.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

PURPOSE OF REVIEW

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH.

RECENT FINDINGS

Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

Half-Saline Versus Normal-Saline as Irrigation Solutions in Burr Hole Craniostomy to Treat Chronic Subdural Hematomata: A Randomized Clinical Trial

OBJECTIVE

This study aimed to evaluate the efficacy and safety of half-saline (HS) serum as an irrigation solution in chronic subdural hematoma (CSDH) surgery using the burr hole craniostomy (BHC) technique.

METHODS

This randomized clinical trial was conducted in university hospital referral centers from 2020 to 2021. Sixty-three patients with CSDH eligible for BHC were primarily enrolled. Two patients were excluded because of concurrent stroke. Sixty-one patients were randomly allocated into case (HS=30) and control (normal-saline [NS]=31) groups. HS was used to irrigate the hematoma in the case group and NS was used in the control group. The patients were followed-up. Clinical variables including demographic and medical findings, postoperative computed tomography findings, postoperative complications, hospitalization period, recurrence rate, and functional status measured by the Barthel type B index were recorded.

RESULTS

Forty-six of 61 patients were male (75.4%), and the patients' mean age was 65.4±16.9 years, with equal distribution between the 2 groups. Postoperative effusion and postoperative hospital stay duration were significantly lower in the HS group than in the NS group (p=0.002 and 0.033, respectively). The postoperative recurrence within 3 months in both groups was approximately equal (6.6%). In terms of functional outcomes and postoperative complications, HS showed similar results to those of NS.

CONCLUSION

HS as an irrigation fluid in BHC effectively reduced postoperative effusion and hospital stay duration without considerable complications.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials Identifier: IRCT20200608047688N1.

Twist drill craniostomy vs burr hole drainage of chronic subdural hematoma: a systematic review and meta-analysis

INTRODUCTION

There is a clinical equipoise between burr hole drainage (BHD) or twist drill craniotomy (TDC) as initial surgical intervention in patients with chronic subdural hematoma (cSDH). Moreover, the impact of type of postoperative drainage is not well elucidated. We performed a systematic review and meta-analysis comparing outcomes following BHD and TDC for initial surgical management in cSDH and to understand the impact of negative suction drainage with TDC.

METHODS

A literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies that directly compared TDC and BHD. The following outcomes were compared between TDC and BHD: mortality, recurrence, reoperations, complications, and cure rates. Subgroup analysis was performed to determine impact of negative suction drainage with TDC.

RESULTS

Sixteen articles (n = 1,235; TDC: 663; BHD: 591) met inclusion criteria. Although complications (OR: 0.68, 95% CI: 0.38-1.23, p = 0.21; I² = 31%), recurrence (OR: 1.16, 95% CI: 0.84-1.62, p = 0.37; I² = 28%), cure (OR: 1.11, 95% CI: 0.72-1.72, p = 0.64, I² = 34%), and mortality rates (OR: 1.20, 95% CI: 0.60-2.41; p = 0.61; I² = 0%) were not significantly different between the two groups, TDC was associated with a higher reoperations than BHD (OR: 1.48, 95% CI:1.01-2.16, p = 0.04; I² = 41%). Subgroup analysis demonstrated that TDC with negative suction drainage conferred equivalent reoperation rates as BHD (OR: 0.75, 95% CI: 0.24-2.35; p = 0.62; I² = 65%); however, TDC without negative suction was associated with higher reoperations (OR: 1.62, 95% CI: 1.08-2.42; p = 0.02; I² = 40%).

CONCLUSION

A systematic review and meta-analysis of available literature directly comparing TDC and BHD for primary evacuation of cSDH did not demonstrate clear superiority of either technique, although reoperations may be higher following TDC. Use of negative suction drainage with TDC may lead to similar rates of reoperation as BHD.

Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma

Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.

Bedside single burr hole craniostomy drainage of chronic subdural hematoma in the emergency room: A useful option in resource challenged settings

Background

In resource challenged environments, the standard treatment of chronic subdural hematoma (CSDH) in the theater may be delayed because of the endemic financial constraint and logistic problems with consequent negative impact on the outcome. An emergency bedside burr hole craniostomy with a local anesthetic at the accident and emergency ward may be lifesaving in patients presenting in extreme neurological conditions in these settings.

Case Description

We presented three patients (one male and two females) with CSDH who presented at our service in poor neurological condition. The patients were between 49 and 70 years. The Glasgow Coma Score ranged from 3 to 6. The three patients had respiratory and pupillary abnormalities at presentation. They all had bedside single frontal burr hole craniostomy drainage of the hematoma under local anesthesia at the accident and emergency unit of the hospital. Surgery was done within 1 h of review by the neurosurgical team in all cases. The duration of hospital stay ranged from 8 to 24 days. The outcome was good in all cases.

Conclusion

Bedside single burr hole craniostomy at the accident and emergency unit may be lifesaving in patients with CSDH who present in extreme neurological condition but in whom prompt standard surgical treatment in the theater is not feasible.

Modified bedside twist drill craniostomy for evacuation of chronic subdural haematoma

Introduction

Standard 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.

Aim

To demonstrate the specific features of CSDH that affect the surgeons’ preferences when selecting patients for TDC.

Material and methods

A 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.

Results

Of 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.

Conclusions

Twist 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.

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.

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

PURPOSE OF REVIEW

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 10 mm in size or those associated with more than 5-mm midline shift are deemed operative.

RECENT FINDINGS

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.

Single Parietal Burr-hole Craniostomy with Irrigation and Drainage for Unilateral Chronic Subdural Hematoma in Young Adults <40 Years: A Rationale behind the Procedure

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. It is mostly a disease of elderly population with very little data about the young patients. There is also the debate regarding treatment strategies. We decided to determine the overall efficacy of the single burr-hole craniostomy (SBHC) for unilateral CSDH in young adults <40 years.

SUBJECTS AND METHODS

We performed a retrospective study of young patients undergoing SBHC for unilateral CSDH between January 2013 and June 2016 at our institution. Medical records were assessed based on patient characteristics in the form of sex of the patient, etiology, presenting symptoms, comorbidities, and signs including Glasgow Coma Scale, computed tomography (CT) brain findings (site and thickness of SDH with midline shift), and intraoperative presence of chronic/subacute component.

RESULTS

Mean age of the patient was 33.69 years (range 18-40 years), mean thickness of SDH was 15.47 mm, and mean midline shift was 11.26 mm. 61.54% patients were male, trauma being the most common etiology (92.31%) with most common presenting complaint being headache (90.38% patients). 69.23% patients presented within 1 day of onset of symptoms. On CT scan, most of the patients were having SDH thickness between 11 and 20 mm (67.31%) with midline shift of 6-10 mm (53.85%). Right-sided SDH was present in 53.85%. Intraoperatively, 63.46% patients had subacute SDH whereas 34.61% had chronic component. There were total 2 recurrences (3.85%).

CONCLUSIONS

Young adults who present with unilateral CSDH usually have a history of trauma. They have shorter duration of symptoms and present mainly with the features of raised intracranial pressure such as headache and vomiting. SBHC with irrigation and drainage has excellent result for unilateral CSDH in young adults compared to other methods of drainage and should be considered treatment of choice unless contraindicated.