External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults

Peng, Deqing; Zhu, Yongjian

doi:10.1002/14651858.cd011402.pub2

Cited by 40 publications

(39 citation statements)

References 37 publications

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“…Our data support some previous findings. Our recurrence rate (n = 278/978; 28%), is toward the high end of what is reported in the literature [22,31,40]. Of the total sample of 978, 5% (n = 49) of the patients undergoing a second surgery were asymptomatic.…”

Section: Comparison Of the Current Findings To Prior Literaturesupporting

confidence: 52%

“…Surgical treatment is recommended in CSDH patients with neurological symptoms, and the preferred surgical technique is burr-hole drainage [26,37]. Recurrence is common, ranging from approximately 5 to 30%, and a reduced recurrence rate is observed with external subdural drains [22,31,40]. Routine postoperative CT can potentially detect recurrent CSDH before clinical deterioration occurs [9].…”

Section: Introductionmentioning

confidence: 99%

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Chronic subdural hematoma—incidence, complications, and financial impact

et al. 2020

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Objective To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT). Methods A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical followup visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland). Results The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/ 100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia. Conclusions Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

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Section: Comparison Of the Current Findings To Prior Literaturesupporting

confidence: 52%

Section: Introductionmentioning

confidence: 99%

Chronic subdural hematoma—incidence, complications, and financial impact

et al. 2020

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“…There is some evidence that postoperative drains lower the number of symptomatic recurrences in CSDH. 28 However, in our cohort, drain usage was not predictive for re-intervention (data not shown), and there was no significant difference in number of re-operations between hospitals even after correcting for postoperative drain usage.…”

Section: Discussionmentioning

confidence: 52%

International practice variation in postoperative imaging of chronic subdural hematoma patients

Hulsbergen

Yan

Stopa

et al. 2019

Journal of Neurosurgery

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OBJECTIVEThe 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.METHODSThe 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.RESULTSBWH 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).CONCLUSIONSWhile 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.

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“…We based the standard rate of reoperations (9.6%) on the results from a recent Cochrane review that reported the recurrence rates after CSDH evacuation followed by subdural drainage in six randomised controlled trials (RCTs) with more than 30 patients per treatment arm. 2 This yielded a maximum allowed margin of 9.0% to achieve non-inferiority. Following a consensus meeting with the trial investigators, the non-inferiority margin was lowered to 7.5%.…”

Section: Sample Sizementioning

confidence: 99%

“…1 With current treatment strategies, the recurrence rate after CSDH treatment is approximately 10%. 2 Low risk of bias evidence exists on the role of subdural drain in recurrence rate reduction but the role of intraoperative irrigation is more controversial. Our literature review revealed a total of 10 studies assessing the effect of intraoperative irrigation: only one study employed a randomised study protocol 3 while the others were retrospective analyses.…”

Section: Introductionmentioning

confidence: 99%

Finnish study of intraoperative irrigation versus drain alone after evacuation of chronic subdural haematoma (FINISH): a study protocol for a multicentre randomised controlled trial

et al. 2020

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IntroductionChronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past, reoperation rates as high as 20%–30% were described for CSDH recurrences. However, following the introduction of subdural drainage, reoperation rates dropped to approximately 10%. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural drainage. Yet, the role of intraoperative irrigation has not been established. If there is no difference in recurrence rates between intraoperative irrigation and no irrigation, CSDH surgery could be carried out faster and more safely by omitting the step of irrigation. The aim of this multicentre randomised controlled trial is to study whether no intraoperative irrigation and subdural drainage results in non-inferior outcome compared with intraoperative irrigation and subdural drainage following burr-hole craniostomy of CSDH.Methods and analysisThis is a prospective, randomised, controlled, parallel group, non-inferiority multicentre trial comparing single burr-hole evacuation of CSDH with intraoperative irrigation and evacuation of CSDH without irrigation. In both groups, a passive subdural drain is used for 48 hours as a standard of treatment. The primary outcome is symptomatic CSDH recurrence requiring reoperation within 6 months. The predefined non-inferiority margin for the primary outcome is 7.5%. To achieve a 2.5% level of significance and 80% power, we will randomise 270 patients per group. Secondary outcomes include modified Rankin Scale, rate of mortality, duration of operation, length of hospital stay, adverse events and change in volume of CSDH.Ethics and disseminationThe study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District (HUS/3035/2019 §238) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.Trial registration numberNCT04203550

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External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults

Cited by 40 publications

References 37 publications

Chronic subdural hematoma—incidence, complications, and financial impact

Chronic subdural hematoma—incidence, complications, and financial impact

International practice variation in postoperative imaging of chronic subdural hematoma patients

Finnish study of intraoperative irrigation versus drain alone after evacuation of chronic subdural haematoma (FINISH): a study protocol for a multicentre randomised controlled trial

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