Transition of a Clinical Practice to Use of Subdural Drains after Burr Hole Evacuation of Chronic Subdural Hematoma: The Helsinki Experience

Abstract

Background A number of randomised controlled trials have shown the benefit of drain in operative treatment of chronic subdural haematomas (CSDHs). However, few reports describe real life result when adopting the drain placement into clinical practice. We report the results following a change in practice at Helsinki University Hospital from no drain to subdural drain (SD) placement after burr-hole craniostomies for CSDHs. Methods We conducted a retrospective observational study including consecutive patients undergoing burr-hole craniostomies for CSDHs. We compared outcomes between a sixmonth time period when the SD placement was arbitrary (July to December 2015) and a time period when SD placement for 48 h was routine (July to December 2017). Our primary outcome of interest was recurrences requiring reoperation within six months. Furthermore, patient outcome, infections and other complications were assessed. Results A total of 161 patients were included, of which 71 (44%) were in the SD group and 90 (56%) in the non-drain group. There were no differences in age, comorbidities, history of trauma or use of antithrombotic medication between the groups (p>0.05). Recurrences within six months occurred in 18% of patients in the non-drain group compared to 6% in the SD group (p=0.028; OR 0.28; 95% CI 0.09-0.87). There were no differences in neurological outcome (p=0.72), mortality rate (p=0.55), infection rate (p=0.96) or other complications (p=0.20). Conclusions The change in practice from no drain to SD after burr-hole craniostomies for CSDHs effectively reduced the six-month recurrence rate without any effect on patient outcome, infections or other complications.

Demonstration of Brain Expansion in Cases of Chronic SDH during Admission Leads to Decreased Rates of Recurrence

“…All publications studied by us have concluded that the use of a closed drainage system gives significantly reduced rates of reaccumulation as opposed to not using drains after surgery. [11][12][13][14] Our operative philosophy is therefor based on the following points drawn from a study of literature (►Fig. 1):…”

Guidance for chronic subdural hematoma surgery in the novel coronavirus pandemic (Covid-19)

“…Single burr hole, double burr holes, or mini-craniotomy, when compared regarding the amount of drained hematoma (71.7% vs. 73.7% vs. 71.9%), and the postoperative air volume in the subdural space was practically the same. 72 A study 21 was done at Helsinki University Hospital with two groups of patients with CSDH: one with the position of a drain during the CSDH surgery and another without a drain. The recurrence rate was 18% in the non-drain group, and 6% in the drain group.…”

“…The most interesting thing was that there was no effect on patient outcomes, infections, or other complications. 21 The critical point is that we may have to reoperate a small group of patients, as in any other technique already used, 50,73 but it is imperative to avoid preventable complications in any way. The authors believe that complications with the procedure are underreported.…”

“…13,[16][17][18] It is incredible that even today, after more than a hundred years since neurosurgery was formally instituted, there is still no consensus on how we should operate patients with CSDH. 19,20 There is still much doubt as to whether we should make one or two burr holes to drain the hematoma, use an intracranial drain to wash the cavity, leave a closed-system drainage in the postoperative period, 13,21 use a subgaleal drain 22 , continue prolonged drainage (≥3 days) in the postoperative period, 23 perform a bedside percutaneous twist drill craniostomy, 24 mini--craniotomy assisted by an endoscope, or whether we should perform a CT examination in the immediate postoperative period 25 and when reoperating the patient on the basis only of neuroimaging, among other uncertainties. 26 In 2005, a survey 20 on neurosurgical practices in the treatment of CSDH was administered to Canadian neurosurgeons.…”

Effect of drain placement on postoperative radiology following burrhole drainage of chronic subdural hematoma

“…3 The passage of a subdural drain postoperatively following burrhole drainage of ChSDH reportedly leads to decreased recurrence and improved outcomes. 5,9,10 The effect of postoperative drain placement on postoperative radiology following ChSDH evacuation is a topic that has been, however, rarely addressed in the literature. 3 Only a few studies have assessed the changes that the passage of a drain has on postoperative radiology.…”