The role of subgaleal suction drain placement in chronic subdural hematoma evacuation

Mini-Perforated Craniotomy with Subperiosteal Drain for Evacuation of Chronic Subdural Hematoma: A New Technique and Clinical Study

Purpose Chronic subdural hematoma (cSDH) is a frequent disease of the elderly with favorable outcomes. The main choice of treatment is surgery. Along with many surgical techniques described for evacuation of cSDH, we are presenting the preliminary outcomes of a novel surgical method, mini-perforated craniotomy with a subperiosteal drain.

Materials and Methods Patients in whom cSDH with thickness of >10 mm was observed in computed tomography (CT) scans with parenchymal compression and/or midline shift were included in this study. Age, sex, complaint, neurological status, and medical history were recorded along with CT findings. Mini-perforated craniotomy was performed on all patients. A subperiosteal drain was used. The postoperative follow-up period was 3 months.

Results Ten cSDH patients who were admitted to Prof. Dr. Cemil Tascioglu City Hospital between December 2020 and May 2021 were included in this study. The mean age was 64.3 ± 6.272, and the most common admission complaint was a headache. Postoperatively, one patient showed acute rebleeding after the operation due to dual anticoagulant therapy. Besides, in 3 months follow-up, rebleeding, subdural or epidural effusion, wound infection, or cosmetic problems were not observed.

Conclusion Mini-perforated craniotomy with a subperiosteal drain may be an alternative method for evacuation of cSDH with low complication rates especially when the hematoma is suspected to be septated.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.

Burr Hole Surgery for Drainage of Chronic and Subacute Subdural Hematomas: Low Recurrence Rate in a Single Surgeon Cohort

Background: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available.

Methods: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence.

Results: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%.

Conclusion: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.

Comparative Study of Subgaleal and Subdural Closed Drain in Surgically Treated Cases of Chronic Subdural Hematoma

Background:

Chronic subdural hematoma (CSDH) is seen most common in geriatric patients, and trauma is the most important reason for CSDH. Operative treatment of CSDH in symptomatic patients is yet the gold standard of therapy because it allows decompression of the subdural space and aids improvement in neurological status. Burr-hole craniostomy is the most common accepted treatment for CSDH. There is still controversy regarding which type of drain placement is best in the outcome: subdural or subgaleal drain.

Aim:

The aim of the study was to compare the outcome of subgaleal versus subdural drain in surgically treated patients of CSDH.

Materials and Methods:

Patients were assigned by simple random sampling in two groups. The study was conducted from February 2016 to July 2017. A total of 70 patients were enrolled into the study and were divided in two groups (Group 1 – Subgaleal drain; Group 2 – Subdural drain). Statistical analysis was done using Chi-square and t-test. Outcome was assessed at the end of hospital stay by modified Rankin scale. Postoperative computed tomography scan was done after 24 h of surgery.

Results:

This study concluded that both types of drains are equally effective for the treatment of CSDH. There is a statistically significant difference in the occurrence of seizure in both the groups as there was no seizure in subgaleal drain group compared to 5 (14.3%) patients who had seizures postoperatively in subdural drain group (P = 0.020). There was insignificant difference with respect to preoperative Glasgow Coma Scale/sex/preoperative hematoma volume/postoperative hematoma volume/preoperative midline shift.

Conclusion:

Subgaleal drain is safe and technically easy, as subgaleal drain has no direct contact with brain parenchyma, thus less chances of brain laceration, intracerebral hematoma formation, and seizures.

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 vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial)

BACKGROUND

The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes.

OBJECTIVE

To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD.

METHODS

Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay.

RESULTS

Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups.

CONCLUSION

Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice

Recurrence Rate of Chronic Subdural Hematoma after Evacuating It by Two Large Burr Holes, Irrigation, and Subgaleal Low-Pressure Suction Drainage

Background:

There are no current standard operative steps for chronic subdural hematoma (CSDH). The aim of this study was to detect the recurrence rate after drainage of a unilateral diffuse CSDH by combining certain operative steps.

Materials and Methods:

This is a descriptive, retrospective cohort study that included 47 consecutive adult patients who underwent evacuation of a unilateral diffuse CSDH by two large burr holes (≥2 cm in diameter) and irrigation of the subdural space by warm saline, followed by placement of a subgaleal Redivac drain under low-pressure suction in our university hospital from August 2012 to August 2016. There were 29 men and 18 women with a mean age of 69.1 years.

Results:

All the operations were uneventful. All the patients had adequate drainage of their subdural hematomas, and all patients were discharged alert and oriented. No incidence of recurrence within 12 months after surgery.

Conclusion:

This study demonstrated that surgical management of a unilateral diffuse CSDH in adult patients by two large burr holes, irrigation, and a subgaleal Redivac low-pressure suction drainage was effective and associated with no recurrence.

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.

Suction forces generated by passive bile bag drainage on a model of post-subdural hematoma evacuation

BACKGROUND

Passive drainage systems are commonly used after subdural hematoma evacuation but there is a dearth of published data regarding the suction forces created. We set out to quantify the suction forces generated by a passive drainage system.

METHOD

We created a model of passive drainage after subdural hematoma evacuation. We measured the maximum suction force generated with a bile bag drain for both empty drain tubing and fluid-filled drain tube causing a siphoning effect. We took measurements at varying heights of the bile bag to analyze if bile bag height changed suction forces generated.

RESULTS

An empty bile bag with no fluid in the drainage tube connected to a rigid, fluid-filled model creates minimal suction force of 0.9 mmHg (95% CI 0.64-1.16 mmHg). When fluid fills the drain tubing, a siphoning effect is created and can generate suction forces ranging from 18.7 to 30.6 mmHg depending on the relative position of the bile bag and filled amount of the bile bag. The suction forces generated are statistically different if the bile bag is 50 cm below, level with or 50 cm above the experimental model.

CONCLUSION

Passive bile bag drainage does not generate significant suction on a fluid-filled rigid model if the drain tubing is empty. If fluid fills the drain tubing then siphoning occurs and can increase the suction force of a passive bile bag drainage system to levels comparable to partially filled Jackson-Pratt bulb drainage.