Burr hole craniostomy versus minicraniotomy in chronic subdural hematoma: a comparative cohort study.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. In surgical management of CSDH, there is a lack of standardized guidelines concerning surgical techniques and a lack of consensus on which technique(s) are optimal. Neurosurgical centers have shown a wide variation in surgical techniques. The purpose of this study was to compare two different surgical techniques, one burr hole craniostomy with an active subgaleal drain (BHC) and minicraniotomy with a passive subdural drain (MC). METHODS: We conducted a multicenter retrospective cohort study at two neurosurgical centers in Sweden which included patients with unilateral CSDHs that received surgical treatment with either BHC or MC. The primary outcomes in comparison of the techniques were 30-day mortality, recurrence rate, and complications according to the Landriel Ibañez grading system for complications. RESULTS: A total of 1003 patients were included in this study. The BHC subgroup included 560 patients, and the MC subgroup included 443 patients. A 30-day mortality when comparing BHC (2.3%) and MC (2.7%) was similar (p = 0.701). Comparing recurrence rate for BHC (8.9%) and MC (10.8%) showed no significant difference (p = 0.336). We found that medical complications were significantly more common in the MC group (p = 0.001). Surgical complications (type IIb) was also associated with the MC group (n = 10, p = 0.003). Out of the 10 patients with type IIb complications in the MC group, 8 had postoperative acute subdural hematomas. CONCLUSIONS: BHC was comparable to MC concerning 30-day mortality rate and recurrence rates. We did, however, find that MC was significantly associated with medical complications and serious surgical postoperative complications.

Risk factors for need of reoperation in bilateral chronic subdural haematomas.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most common neurosurgical diseases. A subtype of CSDH is bilateral chronic subdural haematoma (bCSDH) which represents 20-25% of patients with CSDH and has a higher recurrence rate. There is no clear consensus on how bCSDH should be treated regarding upfront unilateral- or bilateral evacuation of both haematomas. The purpose of this study was to identify risk factors associated with reoperation of bCSDH. METHODS: A total of 326 patients with radiological evidence of bCSDH were included in this retrospective cohort study where 133 (40.8%) patients underwent primary bilateral evacuation and 193 (59.2%) primary unilateral evacuation. The two centres operated using different surgical approaches. Analyses were performed to identify risk factors associated with reoperation of bCSDH. Reoperation rate was defined as reoperation of CSDH on either side of the hemisphere within 3 months after primary evacuation. RESULTS: The cohort had a total reoperation rate of 26.4%. Patients which underwent unilateral evacuation had a reoperation rate of 32.1%, and the bilateral group had a reoperation rate of 18.0% (p=0.005). Multivariable logistic regression identified unilateral evacuation (OR 1.91, p=0.022) and complications according to Ibanez (OR 2.20, p=0.032) to be associated with the need of reoperation of bCSDH. One-burr hole craniostomy with active subgaleal drain was primarily performed in bilateral approach (69.4%) whereas patients operated with minicraniotomy with passive subdural drain were primarily operated by unilateral evacuation of the larger symptomatic side (92.8%). CONCLUSIONS: Unilateral evacuation of bCSDH was associated with a higher risk for reoperation than upfront bilateral evacuations in this study. There is a need to further discuss the criteria for uni- or bilateral evacuation since patients are treated differently at different centres.