Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures

Abstract

Object In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH). Methods The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T2 (tau-squared), I2, and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis. Results Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage. Conclusions Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.

Chronic Subdural Hematoma with Hypodense on CT-Scan in the Elderly: Surgical Drainage or Conservative Treatment

“…Given the steady increase in the elderly population, diseases associated with old age will become more common, which may lead to an overall decline from the neurological baseline before CSDH onset in this population. Many neurosurgeons advocated that the operative risks in patients over 80 years are prone to outweigh the benefits of surgery due to poor baseline function [3,19,21,22]. In our study, patients over 80 years had significant improved in neurological status on 1-month after surgery while no statistical difference in patients with conservative treatment.…”

“…The total rate of mortality of 3.1% after surgery was lower compared to those previously reported rates range from 8%-44% [2,3,14]. There was not different in respect of rate of mortality between two groups in our cohort, unlike previous reports [21,27].…”

“…Response to surgery has been so satisfactory that this is generally considered the treatment of choice. However, large studies have shown that older age independently contributes to increase the rate of lethality, complications and recurrences after the surgical drainage of chronic SDH [3][4][5].…”

“…Chronic subdural hematoma (CSDH) is a predominantly neurological condition usually affecting elderly individuals, and resulting from trauma, coagulopathy, anticoagulant therapy and vascular malformation [1][2][3] Although CSDH is a serious and frequent entity, there is no consensus regarding the optimal treatment strategy. Response to surgery has been so satisfactory that this is generally considered the treatment of choice.…”

Decompressive craniectomy for malignant middle cerebral artery infarctions: a meta-analysis

“…The studies involved were not exactly the same as previous metaanalysis works. Some of the studies, quoted by previous meta works as RCTs, were downgrade precisely to quasi-RCTs [28] in our study, for their potential bias that might have influence on results. The QuasiRCT is defined as allocating the studies throughout some general characteristics of cases, such as date of birth, day of the week, medical record number, and month of the year, among others.…”