Comparative study of single burr-hole craniostomy versus twist-drill craniostomy in patients with chronic subdural hematoma

Abstract

Background: Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. On accounting its risk-to-benefit ratio, there was always controversy regarding the management of the CSDH as to which procedure is superior. Aims: The aim is to compare the clinical and radiological outcomes in patients of CSDH who have undergone single burr-hole craniostomy (BHC) versus twist-drill craniostomy (TDC). Patients and Methods: A retrospective study was conducted in patients admitted with CSDH who had undergone single BHC or TDC between January 2014 and December 2016. Patients between 18 and 90 years of age were selected. Patients with CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, and mixed density were selected. CT scan findings of CSDH with hyperdense gravity-dependent fluid level were also selected. Patients with CT evidence of multiple septations were excluded from the study. Recurrent CSDH, bilateral CSDH, and CSDH with secondary acute bleed were also excluded. Diagnosis was done using noncontrast CT scan. The maximum thickness of the CSDH was measured in the axial film of CT scan. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline in axial CT film. The mass effect was determined by the effacement of the sulci, sylvian fissure obscuration, or compression of lateral ventricles. The decrease in the signs and symptoms in postoperative period was considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of the MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Patients with significant residue underwent reoperation. Results: There were 63 patients in BHC group and 46 patients in TDC group. The mean age in BHC and TDC groups was 61.39 ± 13.21 standard deviation (SD) and 73.36 ± 10.82 SD, respectively. There were 48 (76.19%) male and 15 (23.81%) female in BHC group. There were 32 (69.57%) male and 14 (30.43%) female in TDC group. In BHC group, 41.27% were on the right side and 58.73% on the left side. In TDC group, 50% were on the right side and 50% on the left side. In BHC group, 82.54% were in the frontotemporoparietal region, 9.52% in the frontoparietal region, 6.35% in the temporoparietal region and 1.58% in the parietooccipital region. In TDC group, 86.95% were in the frontotemporoparietal region, 8.69% in the frontoparietal region, 2.17% in the temporoparietal region, and 2.17% in the parietooccipital region. There was no significant difference in duration of symptoms and history of trauma in both the groups. The symptoms of the patients in BHC versus TDC include weakness of the limbs (44.44% vs. 73.91%), headache (50.79% vs. 32.60%), altered sensorium or decreased memory (44.44% vs....

A comparison of subgaleal active drainage and subdural passive drainage and an analysis of factors affecting chronic subdural hematoma outcomes

“…We found that hematoma density, membrane type, postoperative GOS score, and postoperative drainage time are sig-of CSDH (29), and is the favored surgical option (7). However, some studies recommend TDC over BHC, particularly for older patients with comorbidities (19,22,39).…”

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

“…[32] The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI confidence interval, OR odds ratio GRADE Working Group grades of evidence High certainty: True effect lies close to that of the estimate of the effect Moderate certainty: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: The true effect may be substantially different from the estimate of the effect Very low certainty: The true effect is likely to be substantially different from the estimate of effect The lack of uniform outcomes reporting in patients undergoing surgical evacuation of cSDH is important to consider. [34] For instance, many studies within our meta-analysis defined recurrence as a clinically significant hematoma reaccumulation that warranted re-evacuation [8,10,11,17,27,29], while others measured any reaccumulations as a recurrence. [4,5,21,23,25,26,31,33] Heterogeneity in outcomes reporting was also significant due to highly variable duration of postoperative follow-up ranging from 4 weeks to 4 years.…”

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma

“…Recurrence rates following twist drill trephination are as high as 50% (ranging from 17.4% to 50%). 22,57 Finally, large craniotomy is the most invasive surgical treatment for cSDH. The technique requires general anesthesia and a (>25 mm) bone flap, followed by irrigation and evacuation of the SDH.…”