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.

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.

Double-crescent sign as a predictor of chronic subdural hematoma recurrence following burr-hole surgery.

OBJECTIVE: Subdural hygroma has been reported as a causative factor in the development of a chronic subdural hematoma (CSDH) following a head trauma and/or neurosurgical procedure. In some CSDH cases, the presence of a 2-layered space delineated by the same or similar density of CSF surrounded by a superficial, residual hematoma is seen on CT imaging after evacuation of the hematoma. The aims of the present study were to test the hypothesis that the double-crescent sign (DCS), a unique imaging finding described here, is associated with the postoperative recurrence of CSDH, and to investigate other factors that are related to CSDH recurrence. METHODS: The authors retrospectively analyzed data from 278 consecutive patients who underwent single burr-hole surgery for CSDH between April 2012 and March 2017. The DCS was defined as a postoperative CT finding, characterized by the following 2 layers: a superficial layer demonstrating residual hematoma after evacuation of the CSDH, and a deep layer between the brain's surface and the residual hematoma, depicted as a low-density space. Correlation of the recurrence of CSDH with the DCS was evaluated by multivariate logistic regression modeling. The authors also investigated other classic predictive factors including age, sex, past history of head injury, hematoma laterality, anticoagulant and antiplatelet therapy administration, preoperative hematoma volume, postoperative residual hematoma volume, and postoperative brain reexpansion rate. RESULTS: A total of 277 patients (320 hemispheres) were reviewed. Fifty (18.1%) of the 277 patients experienced recurrence of CSDH within 3 months of surgery. CSDH recurred within 3 months of surgery in 32 of the 104 hemispheres with a positive DCS. Multivariate logistic analyses revealed that the presence of the DCS (OR 3.36, 95% CI 1.72-6.57, p < 0.001), large postoperative residual hematoma volume (OR 2.88, 95% CI 1.24-6.71, p = 0.014), anticoagulant therapy (OR 3.03, 95% CI 1.02-9.01, p = 0.046), and bilateral hematoma (OR 3.57, 95% CI 1.79-7.13, p < 0.001) were significant, independent predictors of CSDH recurrence. CONCLUSIONS: In this study, the authors report that detection of the DCS within 7 days of surgery is an independent predictive factor for CSDH recurrence. They therefore advocate that clinicians should carefully monitor patients for postoperative DCS and subsequent CSDH recurrence.

Minitrephination of the frontal sinus: indications and uses in today's era of sinus surgery.

BACKGROUND: This study reviews the role of frontal sinus minitrephination in today's era of endoscopic sinus surgery. Retrospective chart review was performed of 163 patients undergoing a total of 149 bilateral and 39 unilateral frontal sinus minitrephinations. METHODS: Charts were reviewed for patient demographics and outcomes. Details obtained from the chart included type of surgery performed, reason for minitrephine placement, pathology, Lund score, complications, and endoscopic patency. RESULTS: One hundred eighty-eight minitrephines were placed during 80 modified Lothrop and 108 frontal sinusotomies. Trephines were placed when there was difficulty finding the frontal recess, severe edema/polyps, obstructing frontal cells (type 3/type 4 frontoethmoidal cells and intersinus septum cell), and to aid the dissection and postoperative irrigation during the modified Lothrop. Twelve complications occurred with infection at the trephine site being the most common. Follow-up ranged from 2 to 122 months (average, 25.5 months) with 92% showing endoscopic patency at last visit. CONCLUSION: Frontal sinus trephination is a safe useful procedure that can be extremely helpful in identifying the pathway to the frontal sinus. Fluorescein flushes through the trephine help guide the dissection in a modified Lothrop. Lastly, it may be used in the postoperative period to flush the sinus with saline and steroids to promote patency of the frontal sinus.