Treatment of chronic subdural haematomas – A retrospective comparison of minicraniectomy versus burrhole drainage

Abstract

Primary chronic subdural haematomas remains one of the commonest conditions managed by neurosurgeons. Despite this there is a relative lack of evidence regarding best management and certain treatments such as minicraniectomy, have rarely been assessed in the literature. A retrospective case note review comparing minicraniectomy and burrhole drainage of primary chronic subdural haematoma was therefore performed. We sought to determine the proportion of patients requiring repeat drainage or dandy cannula aspiration following initial surgery and to assess outcome at outpatient follow-up. The mean age of patients undergoing minicraniectomy was 73, compared to 63 in the burrhole group (p < 0.001). 130 patients underwent burrhole drainage, 23 of whom (18%) developed a symptomatic recurrence. 21 (16%) of these patients required repeat drainage. Of the 116 patients who underwent a craniectomy 23 (20%) patients suffered a symptomatic recurrence. 15 (13%) patients required the minicraniectomy to be reopened for further washout (p = 0.48). (8%) patients who underwent burrhole drainage died compared to 20 (17%) patients following craniectomy (95%CI 2 to 18%; p = 0.03). However, controlling for age using logistic logression, showed no significant difference between the two treatment groups in recurrence (p = 0.28) or death (p = 0.06). Craniectomy may be considered as a treatment option particularly in the elderly population and in patients with multiple loculated collections.

Risk factors for chronic subdural haematoma formation do not account for the established male bias

“…Despite these concerns, the frequency of a trauma history (head injury or fall, M:F 50% vs. 57% -the second largest risk factor) compared favourably with 56% reported by Ramachandran et al [18] in a much larger series of 647 CSDH cases. Furthermore, a history of alcohol abuse/dependence (M:F 17% vs. 16%) was also of a similar order to that reported in other studies (11-24%) [19][20][21].…”

“…In particular, there was no significant gender difference in either a history of trauma (head injury or fall) (P = 0.37) or alcohol abuse/dependence/intoxication (P = 0.89). Indeed, frequencies for alcohol abuse/dependence of 11-24% [19][20][21] render it improbable that this risk factor alone could ever explain a 2:1 male bias. Traditional assumptions therefore appear unsound.…”

The surgical management of chronic subdural hematoma

“…Four of these studies were prospective, the remaining ten were retrospective. Six compared TDC to BHC [21,26,61,74,83,98], one compared TDC to a combined group of BHC and craniotomy [36], and the other seven compared BHC to craniotomy [14,29,48,52,60,87,97]. The studies evaluated suggest that TDC may be superior to BHC in terms of infection rate [83], but worse in terms of the proportion of patients that developed signs of clinical deterioration [98].…”

“…Two studies report a 0% rate of recurrence with this technique (Table 2) [6,87]; however, the rate of re-operation from other studies ranged between 12% and 23% [14,48]. Mortality following craniotomy has been reported between 0% and 17% [6,87,97], while mortality of groups combining BHC and craniotomy were between 5% and 13% [36,48]. No studies have specifically examined complication rates in a group of craniotomy-treated patients.…”

Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years

“…Craniotomy remains a valid and safe technique for the management of older patients with emergent intracranial bleeds 14 and is particularly important 37 and successful in treating elderly patients, 7 but is an expensive procedure. 21 It has been reported that the average craniotomy procedure itself costs $15,867 at high-volume centers.…”