Preoperative Fibrinogen Levels and Function as Predictive Factors for Acute Bleeding in the Hematoma Cavity After Burr Hole Drainage in Patients with CSDH.

OBJECTIVE: Burr hole drainage (BHD) is the primary surgical intervention for managing chronic subdural hematoma (CSDH). However, it can lead to postoperative complications such as acute bleeding within the hematoma cavity and hematoma recurrence. The objective of this study is to identify the risk factors for these complications and develop a predictive model for acute hematoma cavity bleeding after BHD in patients with CSDH. METHODS: This study presents a retrospective cohort investigation conducted at a single center. The clinical dataset of 308 CSDH patients who underwent BHD at a hospital from 2016 to 2022 was analyzed to develop and assess a prognostic model. RESULTS: The nonbleeding group exhibited a significant correlation between fibrinogen (FIB) and thrombin time (TT), whereas no correlation was observed in the bleeding group. Notably, both FIB and TT were identified as risk factors for postoperative acute bleeding within the hematoma cavity. We developed a prognostic model to predict the occurrence of postoperative acute bleeding within the hematoma cavity after BHD in patients with CSDH. The model incorporated FIB, TT, coronary artery disease, and Glasgow Coma Scale scores. The model exhibited good discrimination (area under the curve: 0.725) and calibration (Hosmer-Leeshawn goodness of fit test: P > 0.1). Furthermore, decision curve analysis demonstrated the potential clinical benefit of implementing this prediction model. CONCLUSIONS: The predictive model developed in this study can forecast the risk of postoperative acute bleeding within the hematoma cavity, thus aiding clinicians in selecting the optimal treatment approach for patients with CSDH.

MER and increased operative time are not risk factors for the formation of pneumocephalus during DBS.

Although only recently directional leads have proven their potential to compensate for sub-optimally placed electrodes, optimal lead positioning remains the most critical factor in determining Deep Brain Stimulation (DBS) outcome. Pneumocephalus is a recognized source of error, but the factors that contribute to its formation are still a matter of debate. Among these, operative time is one of the most controversial. Because cases of DBS performed with Microelectrode Recordings (MER) are affected by an increase in surgical length, it is useful to analyze whether MER places patients at risk for increased intracranial air entry. Data of 94 patients from two different institutes who underwent DBS for different neurologic and psychiatric conditions were analyzed for the presence of postoperative pneumocephalus. Operative time and use of MER, as well as other potential risk factors for pneumocephalus (age, awake vs. asleep surgery, number of MER passages, burr hole size, target and unilateral vs. bilateral implants) were examined. Mann-Whitney U and Kruskal-Wallis tests were utilized to compare intracranial air distributions across groups of categorical variables. Partial correlations were used to assess the association between time and volume. A generalized linear model was created to predict the effects of time and MER on the volume of intracranial air, controlling for other potential risk factors identified: age, number of MER passages, awake vs. asleep surgery, burr hole size, target, unilateral vs. bilateral surgery. Significantly different distributions of air volume were noted between different targets, unilateral vs. bilateral implants, and number of MER trajectories. Patients undergoing DBS with MER did not present a significant increase in pneumocephalus compared to patients operated without (p = 0.067). No significant correlation was found between pneumocephalus and time. Using multivariate analysis, unilateral implants exhibited lower volumes of pneumocephalus (p = 0.002). Two specific targets exhibited significantly different volumes of pneumocephalus: the bed nucleus of the stria terminalis with lower volumes (p < 0.001) and the posterior hypothalamus with higher volumes (p = 0.011). MER, time, and other parameters analyzed failed to reach statistical significance. Operative time and use of intraoperative MER are not significant predictors of pneumocephalus during DBS. Air entry is greater for bilateral surgeries and may be also influenced by the specific stimulated target.

Recurrent Chronic Subdural Hematoma After Burr-Hole Surgery and Postoperative Drainage: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: Reported recurrence rates of chronic subdural hematoma treated by burr-hole surgery with postoperative drainage vary considerably in the literature. We performed a systematic review and meta-analysis to define the recurrence rate of burr-hole surgery with postoperative drainage. METHODS: PubMed and EMBASE were searched, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. We used the Newcastle-Ottawa scale and Cochrane risk-of-bias tool for quality assessment of included studies and the random-effects model to calculate pooled incidence rates in R with the metaprop function if appropriate. RESULTS: The search yielded 2969 references; 709 were screened full text, and 189 met the inclusion criteria. In 174 studies (34 393 patients), the number of recurrences was reported as per patient and 15 studies (3078 hematomas) reported the number of recurrences per hematoma, for a pooled incidence of 11.2% (95% CI: 10.3-12.1; I 2 = 87.7%) and 11.0% (95% CI: 8.6-13.4; I 2 = 78.0%), respectively. The pooled incidence of 48 studies (15 298 patients) with the highest quality was 12.8% (95% CI 11.4-14.2; I 2 = 86.1%). Treatment-related mortality (56 patients) has a pooled incidence of 0.7% (95% CI 0.0-1.4; I 2 = 0.0%). CONCLUSION: The recurrence rate of chronic subdural hematoma treated by burr-hole surgery and postoperative drainage is 12.8%.

Craniotomy hematoma was removed from the bone flap and multiple holes were drilled on the bone flap: A case report.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common disease in neurosurgery department. Burr-hole drainage is the main surgical treatment. And the recurrence rate is as high as 25%. CASE REPORT: In this case, a male patient with CSDH in the left frontotemporal parietal region underwent 2 drilling and drainage operations in the local hospital, but the hematoma recurred after operations. Being unable to bearing the repeated and progressive aggravation of headache, he came to our hospital for treatment. After considering the comprehensive situation, we use a new surgical method, removal of hematoma by drilling multiple holes in the lateral skull, to cure the patient. CONCLUSIONS: We get inspirations from the treatment of moyamoya disease surgery, through the bone holes the scalp forms many "meat column" like structures which have powerful capability in absorption, so the scalp could deep into the hematoma, then the CSDH could be cured. Provide a new surgical method for the treatment of refractory CSDH.

Reducing morbidity associated with subdural drain placement after burr-hole drainage of unilateral chronic subdural hematomas: a retrospective series comparing conventional and modified Nelaton catheter techniques.

PURPOSE: Placement of a subdural drain after burr-hole drainage of chronic subdural hematoma (cSDH) significantly reduces risk of its recurrence and lowers mortality at 6 months. Nonetheless, measures to reduce morbidity related to drain placement are rarely addressed in the literature. Toward reducing drain-related morbidity, we compare outcomes achieved by conventional insertion and our proposed modification. METHODS: In this retrospective series from two institutions, 362 patients underwent burr-hole drainage of unilateral cSDH with subsequent subdural drain insertion by conventional technique or modified Nelaton catheter (NC) technique. Primary endpoints were iatrogenic brain contusion or new neurological deficit. Secondary endpoints were drain misplacement, indication for computed tomography (CT) scan, re-operation for hematoma recurrence, and favorable Glasgow Outcome Scale (GOS) score (≥ 4) at final follow-up. RESULTS: The 362 patients (63.8% male) in our final analysis included drains inserted in 56 patients by NC and 306 patients by conventional technique. Brain contusions or new neurological deficits occurred significantly less often in the NC (1.8%) than conventional group (10.5%) (P = .041). Compared with the conventional group, the NC group had no drain misplacement (3.6% versus 0%; P = .23) and significantly fewer non-routine CT imaging related to symptoms (36.5% versus 5.4%; P < .001). Re-operation rates and favorable GOS scores were comparable between groups. CONCLUSION: We propose the NC technique as an easy-to-use measure for accurate drain positioning within the subdural space that may yield meaningful benefits for patients undergoing treatment for cSDH and vulnerable to complication risks.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma.

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

Towards improved outcome in children treated surgically for spontaneous intracranial suppuration in South Wales.

INTRODUCTION: Spontaneous central nervous system (CNS) infections in children are rare. Treatment involves surgical intervention and antibiotic therapy. We describe a single centre experience of managing this condition in South Wales. METHODS: We performed a retrospective review of surgically managed cases in our unit for patients under 18 years of age between 2008 and 2018. Data were collected regarding aetiology, location, microbiology examination, treatment and outcomes. RESULTS: Twenty-six patients were identified of which 25 case notes were available. Fifteen were male and 10 were female. Median age was 12 years (age range 0.3-17 years). Seven patients (28%) had a burr-hole aspiration and 18 (72%) underwent craniotomy. A second procedure was performed in 10 (40%) and a third procedure in two (8%). Fourteen (56%) had a brain abscess, 10 (40%) had subdural empyema (one was bilateral) and one (4%) had an extradural empyema. Fifteen (60%) had a raised WCC (>11.5 × 109/L) and 22 (88%) had a CRP of >10 mg/L at presentation. Three (12%) patients had a normal WCC and CRP at presentation. Overall, 12 (48%) were secondary to sinus infection, with the most common organism being Streptococcus. Seven (28%) were due to otitis media or mastoiditis, six (24%) had no cause identified. The mean number of CT/MRI scans was 6.7 (range 3-13). The mean follow-up period was 16.7 months (range 1-117 months). At last follow up, 19 (76%) had a GOS of 5, five (20%) had a GOS of 4 and one (12%) had GOS of 3. There were no deaths. CONCLUSIONS: In Wales, outcomes have improved over time in keeping with other paediatric neurosurgical units in England. Increased availability of imaging resources in our hospital and use of neuro-navigation for all cases in our unit as well as earlier identification of sepsis, communication with microbiologists with dedicated ward rounds and, enhanced identification of causative organisms and contemporary anti-microbials have also contributed towards the improved management of this condition.

Development and Validation of Nomogram-Based Prediction of Chronic Subdural Hematoma Recurrence after Initial Burr-Hole Surgery.

AIM: To establish, and validate a practical nomogram to predict recurrence of chronic subdural hematoma (CSDH) in patients after initial burr-hole surgery. MATERIAL AND METHODS: The prediction model was developed from a training set of 272 patients with CSDH who had undergone standard burr hole with irrigation surgery. A separate external validation cohort comprising 112 patients who underwent the same operation was also included. Least absolute shrinkage and selection operator (LASSO) regression was adopted to minimize the high dimension of data and predictor selection. Binary logistic regression was used to develop the present model. Subsequently, a nomogram was established as the ultimate representation of the prediction model. Area under the curve (AUC) was used to identify the discrimination of the designed predictive nomogram. The calibration plot was used to verify the goodness-of-fit of the nomogram. Finally, Decision curve analysis (DCA) was employed to appraise the clinical applicability of the present nomogram. RESULTS: A total of 3 independent variables were filtered by LASSO analysis from the 22 candidate factors. The AUC of the training and validation sets were 0.833 (95%CI: 0.774-0.894) and 0.817 (95%CI: 0.711-0.922), respectively, which indicated a good discrimination ability. The calibration charts showed that the prediction probability and the actual probability fitted well. The DCA of the prediction model indicated an excellent clinical efficacy. CONCLUSION: The proposed nomogram can quantitatively and conveniently predict the recurrence rate of CSDH after burr hole with irrigation surgery. Besides it can facilitate customized treatment adjustment and follow-up of patients who are at a high-risk of recurrence.

Preventing cerebral spinal fluid leakage following endoscopy through a burr hole using a novel watertight closure: technical note.

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a common complication after neuroendoscopic surgery through a burr hole and can lead to further complications including infection. METHODS: We describe the use of a dural substitute larger than the burr hole itself, placed over the burr hole and then secured underneath a burr hole cover by microscrews running through the graft itself into the underlying skull. RESULTS: This simple technical modification contributes to achieving a watertight seal to aid in preventing CSF leakage in this setting. CONCLUSIONS: Our technical modification of endoscopy through a burr hole may help to prevent postoperative CSF leak and secondary CSF infections.

Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma.

BACKGROUND: Post-traumatic epidural hematoma (EDH) accounts for 1-3% of pediatric closed head injury admissions. There is a 2.5:1 male predominance. Etiology varies by age; motor vehicle collisions are the primary cause of EDH in adolescents. Post-traumatic EDH accompanies up to 4% of adult head injuries, and is associated with 10% mortality in adults and 5% mortality in children. In North America, standard of care for post-traumatic EDH includes decompressive craniotomy or trepanation via burr hole. Such lifesaving care is typically provided in the operating room by consulting neurosurgery teams or other personnel trained in the use of burr hole equipment. CASE REPORT: The case of a 17-year-old female patient who presented to a community emergency department (ED) after being involved in a motor vehicle collision is discussed. At the scene of the accident, she refused emergency medical services transport and was brought to the ED via private vehicle. She quickly decompensated in the ED and required intubation. Neurosurgical services were not available and transport to the nearest pediatric trauma center was delayed due to weather. Decompression and drainage of her EDH was accomplished with an EZ-IO® driver and intraosseous needle under virtual guidance of a pediatric neurosurgeon until definitive care could be obtained. The patient made a full neurologic recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS: EDHs have high morbidity and mortality. In settings without access to neurosurgical services, and where ED access to or familiarity with burr hole equipment is limited, the EZ-IO® device may be a temporizing and lifesaving intervention until definitive neurosurgical care can be obtained.

Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study.

Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.

Factors Associated with Outcomes in Patients with Chronic Subdural Hematoma who Underwent 'Burr Hole Craniotomy'.

Background and Objective: Chronic subdural hematomas (CSDH) is frequently encountered in neurosurgical practice. The aim of this study was to investigate the factors associated with the outcome of Burr Hole Craniotomy. Methods: This study was conducted on 116 patients with CSDH in Be'sat Hospital, an educational hospital, in Kurdistan province, Iran. We used Glasgow outcome scale (GOS) at times of discharge and 1 month after stitch removal as favorable outcome. Student t-test or corresponding nonparametric test (Mann-Whitney U test) and logistic regression were used to assess the relationship between investigated variables and favorable outcome. Results: : The results indicated that the chance of success after surgery in patients with CSDH was different based on several variables. The chance of cure after surgery among CSDH male patients (OR = 12.5), patients who have no atrophy (OR = 25.0), patients with no cardiovascular diseases (OR = 7.14), patients who had no medical complications after surgery (OR = 2.08), and patients with higher GCS score at the time of hospitalization (OR = 1.31) was higher. s: Burr hole drainage technique is a simplified, efficient and reliable method of treating patients with CSDH. Our study highlights various factors including female gender, diffuse brain atrophy, postoperative medical complications, a previous history of cardiovascular disease, and lower GCS score at the time of admission can be related to patients' worse outcome.

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia.

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1-3) (OR = 23.9, 95% CI: 3.1-184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.

Up in Flames: The Safety of Electrocautery Trephination of Subungual Hematomas with Acrylic Nails.

INTRODUCTION: Subungual hematomas are fingertip injuries, generally secondary to blunt trauma, that cause pain due to an accumulation of blood under the fingernail. It is generally considered standard of practice to relieve this accumulation by means of trephination with a hollow tip needle, a heated paper clip, or electrocautery. It has been assumed that due to the flammable properties of acrylic, trephination via electrocautery has the potential to ignite acrylic nails and cause burns and other potentially serious injury, making electrocautery contraindicated in patients with acrylic nails. Our thorough literature review failed to support or refute this assumption; so in the interest of ensuring that this practice is evidence-based, we sought to explore this topic. METHODS: In this study we used electrocautery trephination on acrylic nail products attached to simulated digits and recorded the presence and frequency of ignition events. We hypothesized that ignition would occur with sufficient frequency to support continuing the practice of avoiding electrocautery trephination in subungual hematomas with overlying acrylic nails. RESULTS: In our study, we exposed 200 acrylic nails to trephination with electrocautery, and 83 nails ignited (41.5%). CONCLUSION: While other variables exist, these findings do support the current practice pattern of avoiding trephination with electrocautery in those patients with acrylic nails overlying subungual hematomas.

Chronic Subdural Hematoma Drainage Under Local Anesthesia with Sedation versus General Anesthesia and Its Outcome.

BACKGROUND: Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage. METHODS: This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline. RESULTS: Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4-5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported. CONCLUSIONS: This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Factors which influence the complications of external ventricular cerebrospinal fluid drainage.

BACKGROUND: External ventricular drainage (EVD) is one of the most common neurosurgical procedures in emergencies. This study aims to find out which factors influence the occurrence of EVD-related complications in a comparative investigation of metal needles and polyurethane catheters. This is the first clinical study comparing these two systems. METHODS: Adult patients undergoing pre-coronal EVD placement via freehand burr hole trepanation were included in this prospective study. The exclusion criteria were the open EVD insertion and/or a pre-existing infectious disease of the central nervous system. RESULTS: Two hundred consecutive patients were enrolled. Of these, 100 patients were treated by using metal EVD (group 1) and 100 patients with polyurethane catheters (group 2). The overall complication rate was 26% (misplacement 13.5%, hemorrhage 12.5%, infection 2.5%, and dislocation 1%) without statistically significant differences between both groups. Generalized brain edema and midline shift had a significant influence on misplacements (generalized brain edema: p = 0.0002, Cramer-V: 0.307, OR = 7.364, 95% CI: 2.691-20.148; all patients: p = 0.001, Cramer-V: 0.48, OR = 43.5, 95% CI: 4.327-437.295; group 1: p = 0.047, Cramer-V: 0.216, OR = 3.75, 95% CI: 1.064-13.221; group 2: midline shift: p = 0.038, Cramer-V: 0.195, OR = 3.626, 95% CI: 1.389-9.464) all patients: p = 0.053, Cramer-V: 0.231, OR = 5.533, 95% CI 1.131-27.081; group 1: p = 0.138, Cramer-V: 0.168, OR = 2.769, 95% CI: 0.813-9.429 group 2. Hemorrhages were associated with the use of oral anticoagulants or antiplatelet therapy (p = 0.002; Cramer-V: 0.220, OR = 3.798, 95% CI: 1.572-9.175) with a statistically similar influence in both groups. CONCLUSION: Generalized brain edema has a significant influence on misplacements in both groups. Midline shift lost its significance when considering only the patients in group 2. Patients under oral anticoagulation and antiplatelet therapy have increased odds of EVD-associated hemorrhage. Metal needles and polyurethane catheters are equivalent in terms of patient safety when there are no midline shift and generalized brain edema.

Comparative analysis of safety and efficacy in subperiosteal versus subdural drainage after burr-hole trephination for chronic subdural hematoma.

PURPOSE: The treatment of choice for chronic subdural hematoma (CSDH) has been established as burr-hole trephination with drain insertion; however, controversy remains over the best place for the drainage catheter. In this study, we compare the safety and efficacy of a subperiosteal drain (SPD) with that of a subdural drain (SDD) after one burr-hole trephination for CSDH. METHODS: This retrospective and comparative study includes all CSDH patients treated with burr-hole trephination at our institution between January 2015 and December 2019. 59 patients were treated with SPD insertion (SPD group), and 203 patients were treated with SDD insertion (SDD group). RESULTS: The median hematoma thickness of the SPD group within 24 h after surgery was significantly thicker than that of the SDD group (9.5 mm vs. 7.5 mm, p = 0.003), but the midline shifting of the SPD group did not differ from that of the SDD group (3.8 mm vs. 3.5 mm, p = 0.280). The recurrence rate in the SPD group did not differ significantly from that in the SDD group (13.2% vs. 8.5%, p = 0.351). The frequency of bleeding events after surgery also did not differ significantly (5.1% vs. 3.5% p-value = 0.636). In contrast to surgery-related morbidities, medical morbidities such as pneumonia were significantly higher in the SDD group (4.4% vs. 0.0%, p = 0.044). The all-cause mortality rates during the perioperative period did not differ between the two groups (5.1% vs. 3.4%, p = 0.848). CONCLUSION: Our findings may suggest that burr-hole trephination with SPD insertion had better surgical feasibility and fewer perioperative complications than SDD insertion. The type of anesthesia seems to be related with fewer medical complications at perioperative period. Larger, randomized clinical trials focusing not only the drain type but anesthesia type, are needed to validate our findings.

Subdural Air Increases Postoperative Recurrence of Chronic Subdural Hematoma After Initial Burr-hole Surgery Only in the Very Elderly: A Pilot Study.

OBJECTIVE: Numerous randomized controlled trials have identified risk factors increasing the postoperative recurrence of chronic subdural hematoma (CSDH). Postoperative subdural air is frequently seen on computed tomography imaging. The aim of this study was to test the hypothesis that the presence of significant subdural air postoperatively is related to recurrence of CSDH after burr-hole surgery. METHODS: A single-center, retrospective pilot study analyzed patients 20 years and older who underwent initial burr-hole surgery for CSDH. Data from 452 consecutive patients were included. Significant subdural air was considered to be present when the subdural air area was >4 cm2 in 1 axial CT slice. Correlation of the recurrence and the number of slices that included significant subdural air at postoperative day (POD) 1 was evaluated. Other classic predictive factors were also investigated. RESULTS: The recurrence rate was 13.0% in these 452 cases. After univariate analyses of all the variables, multivariate analysis for age, sex, cerebral infarction, number of slices containing significant subdural air, and maximum depth of the subdural space confirmed that older age and male sex were independent risk factors for recurrence (P = 0.032 and 0.047, respectively). After subdividing cases into older (≥75 years of age)/younger and male/female subgroups, the presence of significant subdural air at POD 1 was identified as an independent risk factor for recurrence in older adults (P = 0.025, OR = 1.12). CONCLUSIONS: Although this is a pilot study, it is suggested that significant postoperative subdural air increases recurrence after initial burr-hole surgery for CSDH in adults ≥75 years of age.