Outcome of contemporary surgery for chronic subdural haematoma: evidence based review

Abstract

Objective: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. Methods: A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty. Results: 48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation). Conclusions: The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years. C hronic subdural haematoma of the elderly is nowadays often considered to be a rather benign entity, ignoring its relatively high mortality and morbidity. When Virchow first described "pachymeningitis haemorrhagica interna," however, it was considered a fatal disorder.1 Over the past 150 years, a dramatic improvement in outcome was achieved following better understanding of the pathophysiology, the introduction of modern imaging methods, and refinement of operative techniques.2 However, mortality of up to 13% is still reported in contemporary literature, [3][4][5][6] which may reflect the fact that up to four deaths a year are related to this condition in a typical neurosurgical department. Although this is one of the most frequent...

Dexamethasone treatment in chronic subdural haematoma

“…Burr hole is a simple and easyto-perform technique with a low morbidity rate (ranging from 0 to 9%) but a rather variable rate of recurrence up to 28% 31 . There is no sound evidence recommending the use of concomitant subdural drainage or irrigation, although class C studies support their use as it does not seem to predispose to infection.…”

“…Thus, hypodense, isodense, hyperdense, those with a level 2009; 20: 346-359 of fresh blood and mixed haematomas were associated with recurrence rates of 0%, 2.3%, 17.2%, 12.5% and 6.5%, respectively. The paper by Weigel et al 31 , following Evidence Based Medicine criteria, reviews the results of surgical treatments of other studies published from 1981 to 2001, including series of, at least, 10 patients and a follow up no less than 90%. They compared the results of the three most commonly used techniques: burr hole, twist-drill craniostomy and craniotomy.…”

“…The effectiveness of surgical treatment has been ascertained in multiple studies 10,18,19,24,31 . The percentage of patients cured with surgery may be as high as 90% with radiological resolution over 60% within the first two months.…”

“…At present, burr-hole or twist-drill craniostomy and drainage are the most widely used surgical techniques 19,24,25,31 . Neurological outcome after surgical evacuation of CSH is known to be remarkably favourable in the great majority of patients 18,30 .…”

Brain Stem Hemorrhage Following Burr Hole Drainage for Chronic Subdural Hematoma -Case Report-

“…However, postoperative complications, including cerebral edema, hematoma re-accumulation, subdural empyema, tension pneumocephalus, and intracranial hemorrhage in other sites, have occasionally been reported. 2,11,18,24,25) Intracranial hematomas following burr hole drainage may occur either close to or remote from the original site, but hemorrhage in the brain stem secondary to the surgery is extremely rare. 2,4,8,14) We treated a 76-yearold man who suffered brain stem hemorrhage after bilateral CSDH evacuation, who fortunately recovered with only mild gait disturbance.…”