Surgical techniques for evacuation of chronic subdural hematoma: a mini-review.

Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.

Comparison of Burr-Hole Craniostomy versus Twist-Drill Craniostomy Operations for Patients with Chronic Subdural Hematoma: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Chronic subdural hematoma (CSDH) represents one of the most common neurologic disorders in the elderly. However, the optimum surgical option remains questionable. This study aims to compare the safety and efficacy of single burr-hole craniostomy (sBHC), double burr-hole craniostomy (dBHC), and twist-drill craniostomy (TDC) in patients with CSDH. METHODS: We searched PubMed, Embase, Scopus, Cochrane, and Web of Science until October 2022 for prospective trials. Primary outcomes comprised recurrence and mortality. The analysis was performed using R software, and the results were reported as risk ratio (RR) and 95% confidence interval (CI). RESULTS: Data from 11 prospective clinical trials were included in this network meta-analysis. We found that dBHC significantly decreased recurrence and reoperation rates compared with TDC (RR = 0.55, CI, 0.33-0.90 and RR = 0.48, CI, 0.24-0.94, respectively). However, sBHC showed no difference compared with dBHC and TDC. There was no significant difference among dBHC, sBHC, and TDC regarding the hospitalization duration, complication rates, mortality, and cured rates. CONCLUSIONS: dBHC seems to be the best modality for CSDH compared with sBHC and TDC. It showed significantly less recurrence and reoperation rates compared with TDC. On the other hand, dBHC showed no significant difference with the other comparators regarding complication, mortality, and cure rates in addition to the hospitalization duration.

Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis.

Background: Chronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking. Methods: All patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort. Results: 110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay. Conclusion: Twist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Butterfly needle tap and suction (BTS) technique: a treatment for recurrent chronic subdural hematoma after burr hole craniostomy.

BACKGROUND: In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle. METHODS: This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications. RESULTS: Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0 ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4 ml in the BTS-alone group and 49.4 ± 12.9 ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein. CONCLUSIONS: The BTS technique is an effective alternative to reoperation with BHC.

Predictors and Outcomes of Subdural Hematomas Managed via Subdural Evacuation Port System.

Background: Subacute subdural hematoma (SDH) is a common pathology most frequently affecting older patients and may be treated operatively through burr holes versus craniotomy or minimally invasively with bedside twist drill craniostomy. Less invasive intervention is favored when possible given a frequently comorbid population. The subdural evacuation port system (SEPS) is a popular treatment option that warrants investigation and reporting of its use and outcomes. Methods: A retrospective review of consecutive patients undergoing SEPS drain placement for chronic or mixed density SDH between 2010 and 2021 was conducted. Outcomes of SDH recurrence, need for operating room procedure after SEPS placement, discharge disposition other than home, and modified Rankin Scale score <3 at discharge were modeled with logistic regression using multiple demographic, clinical, and radiographic features. Results: Ultimately, 86 patients (mean age 68) were included in the analysis with 66 (78%) presenting with mixed-density SDHs. Radiographic factors such as hematoma thickness and midline shift were not associated with the need for an operating room procedure after SEPS placement or discharge disposition. However, the presence of septations and mixed-density SDH versus chronic SDH was significantly associated with increased odds of requiring an operative intervention after SEPS placement. Conclusions: Subacute SDHs are a frequent neurosurgical issue in patient populations where less invasive measures are favored. SEPS drainage continues to be an effective treatment option. However, the presence of septations and mixed-density SDHs has a significantly increased odds of requiring surgical intervention that must be considered in the decision to pursue SEPS drainage.

Assessment of Frailty in Predicting Surgical Outcomes in Patients with Chronic Subdural Hematomas: Retrospective Chart Review.

BACKGROUND: The aim of this study is to determine if frailty, defined as modified frailty index (MFI) >2.7, correlated with worse postoperative outcomes in patients with chronic subdural hematomas (CSDHs). We also compare the predictive ability of the MFI with another widely used frailty measure, the Clinical Frailty Scale (CFS). METHODS: We conducted a retrospective chart review of elderly patients (≥65 years) who underwent a twist-drill craniostomy for the evacuation of CSDH at Hamilton General Hospital, Canada, between 2016 and 2018. The primary outcome was the modified Rankin Scale scores at discharge. Logistic regression analyses and receiver operating characteristic curves were carried out to further analyze the factors that influenced independence and functional improvement at discharge. RESULTS: Frail patients were significantly more dependent at discharge (P < 0.0001) and had a lower rate of functional improvement (P = 0.003). When compared with frailty measured by the MFI, frailty as measured by the CFS had a stronger association with functional independence (odds ratio [OR]: 0.081 [0.031, 0.211] vs. OR: 0.256 [0.124, 0.529]) and functional improvement (OR: 0.272 [0.106, 0.693] vs. OR: 0.406 [0.185,0.889]) on logistic regression analyses. Area under the receiver operating characteristic curve analyses showed that the inclusion of frailty into our predictive models improved accuracy. CONCLUSIONS: Elderly patients presenting with CSDH who are frail (MFI >0.27) have significantly worse functional outcomes following twist-drill craniostomies. Therefore assessing frailty in this population is important before managing these patients, and for this purpose the CFS is a superior predictor of postoperative function than the MFI.

A simple and effective modified technique of twist drill craniostomy for bedside drainage and irrigation of chronic subdural hematoma: Technical and clinical study.

OBJECTIVE: Chronic subdural hematoma (CSDH) is an important health problem observed mostly in elderly population. Here, we aimed to describe and validate a simple modified technique of twist-drill craniostomy (TDC) using easily accessible tools for effective and safe bedside CSDH drainage. METHODS: A detailed description of the new modified TDC technique which allows for sequential drainage and irrigation under physiological conditions is provided. Clinical and radiological characteristics as well as surgical results of the patients undergoing this procedure are also presented. RESULTS: A total of 55 patients (30 M, 25 F) underwent this modified TDC. Mean age was 61.7 ±â€¯12.3 years. Medical comorbidities were common (76.4 %). Subdural hematoma was mostly unilateral (83.6 %). Maximum width of hematoma was 21 ±â€¯4 mm on average (range: 9-38 mm). In total, patients underwent 1.6 ±â€¯0.9 subdural tappings on average (median: 1, range: 1-5). Repeat tappings were performed in 43.6 % of the patients. No mortality, serious morbidity or infectious complications were noted. Pneumocephalus was either absent or minimal in most cases (96.4 %). Mean length of hospital stay was 4.9 ±â€¯4.0 days (median: 3; range: 2-20 days). The clinical outcomes were favorable in 92.7 % of the patients (no craniotomy required and no symptomatic recurrence detected). CONCLUSION: This modified technique of TDC utilizes easily available tools, yields satisfactory radiological and clinical results, allows repeated tappings even in outpatient settings and can thus be readily applied in every neurosurgical unit across the world. It can be an effective alternative to existing procedures for patients with multiple co-morbidities and/or high anesthesia risk, in emergency conditions and busy neurosurgical centers.

Benefits of the Subdural Evacuating Port System (SEPS) Procedure Over Traditional Craniotomy for Subdural Hematoma Evacuation.

BACKGROUND: There remains no consensus on the optimal primary intervention for subdural hematoma (SDH). Although historically favored, craniotomy carries substantial morbidity and incurs significant costs. Contrastingly, the subdural evacuating port system (SEPS) is a minimally invasive bedside procedure. We assessed the benefits of SEPS over traditional craniotomy for SDH evacuation. METHODS: A single-center retrospective cohort study of SDH patients receiving craniotomy or SEPS between 2012 and 2017 was performed. Information regarding demographics, medical history, presentation, surgical outcomes, cost, and complications was collected. Pre- and postoperative hematoma volumes were calculated using 3D image segmentation using Vitrea software. Multivariate regression models were employed to assess the influence of intervention choice. RESULTS: Of 107 patients, 68 underwent craniotomy and 39 underwent SEPS. There were no differences in age, sex, blood thinner use, platelet count, INR, hematoma lateralization, age, volume, or midline shift at presentation between intervention groups. Although there was no difference in percent residual hematoma volume 24-hour postintervention (44.1% vs 45.1%, P = .894), SEPS was associated with lower hospitalization costs ($108 391 vs $166 318, *P = .002), shorter length of stay (4.0 vs 5.8 days, *P = .0002), and fewer postoperative seizures (2.6% vs 17.7%, *P = .048). Reoperation rate was higher after SEPS overall (33.3% vs 13.2%, *P = .048) but comparable to craniotomy in chronic SDH (12.50% vs 7.69%, P = 1.000). CONCLUSION: In this retrospective cohort, SEPS was noninferior to craniotomy at reducing SDH hematoma volume. The SEPS procedure was also associated with decreased length of stay hospitalization costs, and postoperative seizures and demonstrated a comparable recurrence rate to craniotomy for chronic SDH in particular.

Bedside Percutaneous Twist Drill Craniostomy of Chronic Subdural Hematoma-A Single-Center Study.

Background Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. Objectives This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC). Patients and Methods A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Statistical Analysis Statistical analysis is done using Epi Info software. Results The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD. Conclusions CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

Pros and cons of a minimally invasive percutaneous subdural drainage system for evacuation of chronic subdural hematoma under local anesthesia.

OBJECTIVE: Chronic subdural hematoma (CSH) is a common neurosurgical disease among elderly population with concomitant degenerative neurological disorders. This is a retrospective series-control analysis of prospectively collected data, aiming to show advantages and indications of a minimally invasive, percutaneous drainage system for CSH. PATIENTS AND METHODS: We retrospectively analyse the clinical and radiological data of a minimally invasive, percutaneous draining system (Integra ™) used in fifteen patients (Group A; mean age: 75.7) with CSH, and compare them with those obtained from two retrospective series of patients: the first one (Group B 15 patients, mean age 77.1) treated with standard, single-burr hole technique for subdural drainage under general anaesthesia; the second one (Group C 15 patients, mean age 76.4) treated with standard, single-burr hole technique for subdural drainage under local anaesthesia and mild sedation. All The percutaneous procedures (Group A) were performed under local anaesthesia. RESULTS: Mean follow-up was 10.9 (range 3-14), 18.2 (range 10-29) and 15.2 (range 8-28) months in Group A, B and C respectively. Three of 15 and in Group B experienced a worsening of pre-existing neurodegenerative disorders after general anaesthesia. One patient in group C suffering from Parkinson's disease experienced a worsening of gait disturbances. Post-operative CT scans were performed at 48 h and 21 days after the operation. An early post-operative CT-scan, obtained immediately after surgical procedure, was performed in all Group A patients. No differences in CSH evacuation were observed comparing the three groups. Two recurrent hematomas, one in group A and one in group B, required revision. Post-operative hospitalization was similar (5.1 vs 5.7 vs 5.6 days, respectively, in group A, B and C) but analgesics use was lower in Group A. CONCLUSION: Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for a minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders.

Modified bedside twist drill craniostomy for evacuation of chronic subdural haematoma.

INTRODUCTION: Standard craniotomy (SC) and burr hole craniostomy (BHC) are regarded as the standard approaches to chronic subdural haematoma (CSDH). Bedside twist drill craniostomy (TDC), performed at the patient's bedside, was introduced as an alternative to the standard methods. However, clinical and radiological features of patients treated with TDC and BHC/SC have not been compared. AIM: To demonstrate the specific features of CSDH that affect the surgeons' preferences when selecting patients for TDC. MATERIAL AND METHODS: A retrospective analysis of 32 patients treated due to CSDH in the year 2017 at a single institution was performed. Baseline radiological characteristics, clinical status at admission, complication rate and clinical outcomes were compared between BHC/SC and TDC. RESULTS: Of the 32 patients, 5 (15.6%) were treated using TDC and 27 (84.4%) by SC or BHC. The duration of the TDC procedure was significantly shorter than the time of standard therapies (p < 0.01). There were no differences between TDC and BHC/SC in terms of baseline clinical characteristics, including age, gender, head trauma history, diabetes, hypertension, antiplatelet drug use, clinical manifestation and the Glasgow Coma Scale score (all p > 0.05). Patients treated with TDC had a significantly thicker haematoma (TDC vs. BHC/SC: mean 25.3 mm vs. 14.6 mm) (p < 0.01) and demonstrated a smaller midline shift (TDC vs. BHC/SC: mean 0.5 mm vs. 4.0 mm) (p = 0.01) compared to those treated with BHC/SC. CONCLUSIONS: Twist drill craniostomy is a more effective method for CSDH evacuation compared to SC and BHC. This procedure is considered as the first line treatment for patients with a thicker and non-septated haematoma, and with a smaller midline shift.

Efficacy of Trauma Catheter and Mushroom Tip Catheter in Evacuation of Chronic Subdural Hematoma and Complications of Drain Placement.

Objective The aim of this study was to assess the efficacy and complications of trauma catheter versus mushroom tip catheter placement in the evacuation of chronic subdural hematoma via twist drill craniostomy with closed system drainage. Background Chronic subdural hematoma (cSDH) is one of the most frequent neurosurgical pathologies in patients >70 years of age with an estimated incidence of 8.2 per 100,000 people per year. The most common risk factors for cSDH are advanced age, alcohol abuse, seizures, cerebrospinal fluid (CSF) shunts, coagulopathies, blood thinners, and patients at risk for falling. Twist drill craniostomy can be performed at the bedside under local anesthesia, making it an attractive treatment option, especially in poly-morbid patients who are poor surgical candidates. A closed drainage system is placed at the time of surgery to allow continuous drainage and promote postoperative brain expansion. Despite the increasing prevalence, limited literature exists to guide surgical management, particularly in terms of drain management and selection of catheter.  Methods This is a retrospective review of 205 patients from January 2007 to May 2017 at two-level high volume centers for the evaluation and treatment of cSDH. Inclusion criteria include patients >18 years of age with the radiographic presence of a subdural hematoma for greater than three weeks. All patients were managed with either a trauma catheter or mushroom tip catheter. All patients received computed tomography (CT) of the head without contrast prior to subdural drain placement and within 24 hours after subdural drain removal. Exclusion criteria include patients <18 years of age and patients with depressed skull fractures, vascular malformations, subdural empyema, subdural hygroma, or who initially underwent open craniotomy or burr-hole craniotomy. Results Drain efficiency in evacuating the cSDH was assessed using both radiographic and clinical markers. Analysis of 205 patients treated by twist drill craniostomy and the subsequent closed system drainage utilizing either the mushroom tip catheter or trauma catheter revealed that neither catheter was superior in producing a statistically significant change in the maximum thickness of the cSDH (p = 0.35) and midline shift (p = 0.45). Furthermore, when assessing patients clinically via utilization of the Glasgow Coma Scale (GCS), both the trauma catheter and the mushroom catheter did not show a statistically significant difference in improving GCS after the evacuation of the cSDH (p = 0.35). Neither catheter was associated with an increased incidence of hemorrhage with drain placement requiring open surgery (p = 0.12), need for additional drain placement (p = 0.13) or decline in GCS with intervention (p = 0.065). Conclusion Analysis of the 205 patients treated by twist drill craniostomy with closed system drainage for the evacuation of chronic subdural hematoma utilizing either the mushroom tip or trauma catheters revealed that neither catheter was statistically significant in radiographic or clinical improvement in evacuating cSDH. Furthermore, neither catheter was found to be associated with an increased complication risk.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. On accounting its risk-to-benefit ratio, there was always controversy regarding the management of the CSDH as to which procedure is superior. AIMS: The aim is to compare the clinical and radiological outcomes in patients of CSDH who have undergone single burr-hole craniostomy (BHC) versus twist-drill craniostomy (TDC). PATIENTS AND METHODS: A retrospective study was conducted in patients admitted with CSDH who had undergone single BHC or TDC between January 2014 and December 2016. Patients between 18 and 90 years of age were selected. Patients with CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, and mixed density were selected. CT scan findings of CSDH with hyperdense gravity-dependent fluid level were also selected. Patients with CT evidence of multiple septations were excluded from the study. Recurrent CSDH, bilateral CSDH, and CSDH with secondary acute bleed were also excluded. Diagnosis was done using noncontrast CT scan. The maximum thickness of the CSDH was measured in the axial film of CT scan. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline in axial CT film. The mass effect was determined by the effacement of the sulci, sylvian fissure obscuration, or compression of lateral ventricles. The decrease in the signs and symptoms in postoperative period was considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of the MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Patients with significant residue underwent reoperation. RESULTS: There were 63 patients in BHC group and 46 patients in TDC group. The mean age in BHC and TDC groups was 61.39 ± 13.21 standard deviation (SD) and 73.36 ± 10.82 SD, respectively. There were 48 (76.19%) male and 15 (23.81%) female in BHC group. There were 32 (69.57%) male and 14 (30.43%) female in TDC group. In BHC group, 41.27% were on the right side and 58.73% on the left side. In TDC group, 50% were on the right side and 50% on the left side. In BHC group, 82.54% were in the frontotemporoparietal region, 9.52% in the frontoparietal region, 6.35% in the temporoparietal region and 1.58% in the parietooccipital region. In TDC group, 86.95% were in the frontotemporoparietal region, 8.69% in the frontoparietal region, 2.17% in the temporoparietal region, and 2.17% in the parietooccipital region. There was no significant difference in duration of symptoms and history of trauma in both the groups. The symptoms of the patients in BHC versus TDC include weakness of the limbs (44.44% vs. 73.91%), headache (50.79% vs. 32.60%), altered sensorium or decreased memory (44.44% vs. 54.4%), vomiting (19.04% vs. 6.52%), speech abnormalities (15.87% vs. 19.56%), urinary incontinence (25.39% vs. 15.21%), seizure (1.58% vs. 4.34%), and diplopia (4.76% vs. 0%). The mean preoperative Glasgow Coma Scale (GCS) score in BHC versus TDC was 13.44 ± 2.23 SD versus 12.47 ± 2.95 SD limb weakness was noted in 52.38% BHC group and 82.60% TDC group. There was significantly decreased GCS score in TDC group. The number of the patients with limb weakness on affected side was significantly more in TDC group. The mean maximum thickness of the CSDH (in millimeter) in axial CT scan was 17.22 ± 4.29 SD in BHC group and 22.21 ± 4.52 SD in TDC group. The number of patients with MLS was 59 (93.65%) in BHC group and 45 (97.82%) in TDC group. There was significant difference in thickness of CSDH in both the groups. However, there was no significant difference in MLS in both the groups. There was no significant difference in prothrombin time, International Normalized Ratio, and activated partial thromboplastin time values of both the groups. There was significant difference in platelet counts of both the groups. The mean duration of procedure (in minutes) in BHC versus TDC was 79.20 ± 26.76 SD versus 27.47 ± 4.80 SD. The duration of procedure was significantly more in BHC compared to TDC. In postoperative assessment, there was no significant difference in the GCS score, power improvement, power deterioration, clinical improvement, and improvement in CT scans of both the groups. Postoperative CSDH residue requiring reoperation was significantly more in TDC group against the BHC group (13.04% vs. 1.58%). There was no significant difference in the development of acute subdural hematoma (SDH) (4.76% vs. 8.6%), reoperation rate (6.35% vs. 17.39%), complications (9.52% vs. 15.21%), and death (4.76% vs. 10.87%) in BHC group vs. TDC group. There was no significant difference in the period of hospital stay (days) in BHC (8.90 ± 5.89 SD) and TDC groups (7 ± 4.24 SD). CONCLUSION: The duration of procedure was significantly more in BHC than in TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH.

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

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.

Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review.

Introduction Chronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice. Methods  A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests. Results In all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA. Conclusion Intracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.

First-line management of chronic subdural hematoma with the subdural evacuating port system: Institutional experience and predictors of outcomes.

Chronic subdural hematoma (cSDH) is a common condition that disproportionately affects older patients. Given the greater risks of general anesthesia in this population, interest has turned towards less invasive surgical approaches such as the subdural evacuating port system (SEPS; Medtronic, Inc., Minneapolis, MN). There is a relative dearth of information about the outcomes following this procedure. Here, we present our institution's experience with SEPS and analyze factors associated with the outcomes. Using a prospectively maintained institutional database, we retrospectively identified all patients who presented with cSDH and received first line therapy with SEPS. Pre- and post-operative clinical and radiographic data was obtained from the electronic health record. Outcomes included success or failure, Modified Rankin Scale (mRS) at discharge, length of stay (LOS), and discharge disposition. A total of 126 patients met the inclusion criteria (36 females and 90 males; mean age of 71.6 years). None of the pre-procedural clinical or radiographic variables were associated with the likelihood of a successful outcome. Increasing age was associated with non-routine hospital discharge (p = 0.003), and lower presenting GCS was associated with longer hospital stay (p = 0.005). Greater thickness of the cSDH was associated with a lower likelihood of having a favorable outcome (mRS ≥ 3; p = 0.003). SEPS is an effective first-line therapy for cSDH. Variables previously reported to limit the effectiveness of the technique (presence of septations, mixed density collections) were not associated with treatment failure.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom.

OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Twist Drill Procedure for Chronic Subdural Hematoma Evacuation: An Analysis of Predictors for Treatment Success.

BACKGROUND: Twist drill craniostomy (TDC) is a minimally invasive and cost-effective technique to treat chronic subdural hematomas (CSDHs). Predictors for treatment success such as imaging characteristics, hematoma volume, and drainage volume are not established; thus, they are purpose of this analysis. MATERIAL AND METHODS: We retrospectively evaluated all data of patients with CSDH undergoing TDC in our institution between January 2010 and December 2013. We analyzed imaging characteristics (extension and composition), volumetrically calculated pre- and postoperative hematoma volumes, measured drainage volume, and clinical course. Primary treatment success was defined as sufficient if definitive treatment was achieved via a single TDC (TDC-1) and insufficient if more than one TDC was needed. The need for open surgical evacuation was defined as treatment failure. RESULTS: Data of 233 patients undergoing 387 TDCs were available for our study. A total of 67% of TDCs treated CSDHs effectively, whereas the remainder required further open surgical evacuation. Via use of the median-split-method, we found that sufficient treatment was achieved more frequently in smaller hematomas (P < 0.05). Treatment effectiveness was neither correlated with hematoma image characteristics (presence of membranes: P = 0.11, extent of chronification: P = 0.55) nor with the respective drainage volume (P = 0.95). Residual hematoma volume was consistently greater than expected by drainage calculation (P < 0.05). CONCLUSIONS: TDC is an effective treatment option for CSDH. Sufficient treatment with single TDC was more common in smaller hematomas with an associated smaller residual hematoma. Failure of brain re-expansion after TDC may increase the treatment failure rates. In these cases, an open surgical evacuation might accelerate treatment and clinical recovery.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom.

OBJECTIVE: Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS: Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS: Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS: This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Twist-Drill or Burr Hole Craniostomy for Draining Chronic Subdural Hematomas: How to Choose It for Chronic Subdural Hematoma Drainage.

OBJECTIVE: Although twist-drill craniostomy (TDC) has a number of procedural advantages and an equivalent outcome compared to burr hole craniostomy (BHC) for the treatment of chronic subdural hematomas (CSDHs), the latter technique remains the preferred method. We analyzed symptomatic CSDHs in whom TDC at the pre-coronal suture entry point (PCSEP) was the primary method for hematoma drainage and BHC on the parietal was the secondary option. METHODS: CSDHs in 86 consecutive patients were included. TDC at the PCSEP, which is 1 cm anterior to coronal suture at the level of the superior temporal line, was the primary operational technique when the hematoma thickness was suitable, and BHC was performed via the parietal when TDC was unreasonable or failed. The clinical feasibility and outcomes of these approaches were analyzed. RESULTS: Of the 86 patients, 68 (79.1%) were treated by TDC, and 18 (20.9%) by BHC. All patients showed improvements in their symptoms after hematoma drainage. Neither morbidity nor mortality was associated with either technique, and there were no differences in drainage days between the groups. Ten patients had bilateral hematomas and were treated using TDC. Two patients were not sufficiently treated by TDC and, as a result, BHC was applied. Only six hematomas (7% of 86 hematomas) exhibited insufficient thickness on the computed tomography to perform TDC. CONCLUSION: When the hematoma was thick enough, a majority of the CSDHs were drained using TDC at the PCSEP as the first procedure, which was especially useful for bilateral hematomas and in elderly patients.