Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

Abstract

Background: A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review. Case presentation: A total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients' baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30-120 min). The mean distance of midline shift was 14.6 mm (10-20 mm). The preoperative GCS in all patients ranged from 4 to 13 (median, 9). The mean duration of the operation was 14.4 min (6-19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0-2) at 6 months after surgery. Conclusions: TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

“…[15,[35][36][37][38][39] Miki et al [15] performed endoscopic surgery under general anesthesia in 26 patients with ASDH over 65 years of age, achieving a mean hematoma reduction rate of 90% and a favorable outcome of 69.2%. Huang et al [17] reported that seven patients over 65 years of age with ASDH achieved more than 70% of hematoma evacuation using twist drill craniotomy under local anesthesia. In patients with ASDH, the delay from injury to surgery is an essential factor influencing a patient's mortality rate.…”

“…As a result, minimally invasive surgery has become an essential topic of discussion, as revealed in a recently published study of minimally invasive surgical techniques such as endoscopic surgery in patients with ASDH at a high risk of complications associated with a large craniotomy. [13][14][15][16][17] In this study, we report an alternative strategy for primary treatment and rescue that involves reducing the mass effect of a subdural hematoma through minimally invasive surgery without general anesthesia.…”

Surgical safety criteria for burr hole surgery with urokinase in patients with acute subdural hematoma: Retrospective comparison between burr hole surgery and craniotomy

“…Previous studies also reported positive results of burr hole surgery in patients for whom general anesthesia or craniotomy have a high risk. [ 6 , 11 ]…”

“…[ 2 , 14 , 15 ] It was also used in previous reports of burr hole surgery for ASDH, and no complications were reported. [ 1 , 6 ] We also used urokinase, expecting for hematolytic effect. A median of 3 days was required for hematoma excretion after burr hole surgery.…”

“…Several studies reported burr hole surgery or twist drill craniostomy on ASDH patients without subsequent craniotomy. [ 1 , 6 , 11 ] In this report, we retrospectively compared the patient background and outcomes of burr hole surgery and craniotomy for ASDH in our department to determine the safety criteria for burr hole surgery.…”