Local anesthesia versus general anesthesia for surgical drainage of chronic subdural hematoma: a systematic review and meta-analysis.

PURPOSE: The optimal anesthetic technique for surgical drainage of chronic subdural hematoma (CSDH) is still uncertain. We performed this systematic review and meta-analysis to determine if local anesthesia with or without sedation (LA) or general anesthesia (GA) results in better outcomes for surgical drainage of CSDH. METHODS: We searched PubMed, EMBASE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for randomized controlled trials (RCTs) and prospective or retrospective studies that compared GA vs LA for adult patients undergoing surgical drainage of CSDH and reported at least one outcome of interest. Primary outcomes of interest included total duration of surgery, recurrence rate, and length of hospital stay (LOS). Secondary outcomes included intraoperative adverse events, postoperative complications, and postoperative mortality. RESULTS: Eight studies (1,542 patients; 926 LA; 616 GA) were included-two were RCTs and six were observational studies. Pooling the estimates of all available studies, we found that LA was associated with a decreased mean LOS by about two days (95% confidence interval [CI], -3.47 to -0.77; P = 0.01; low certainty of evidence) as well as a lower risk of postoperative complications (odds ratio, 0.31; 95% CI, 0.17 to 0.58; P = 0.004; very low certainty of evidence). There was no significant difference in terms of duration of surgery, recurrence rate, intraoperative adverse events, or mortality. The quality of the observational studies was poor to fair, largely because of heterogeneity among the studies. Among the RCTs, one had a low risk of bias and one was deemed to be at high risk of bias. CONCLUSIONS: Local anesthesia with/without sedation for surgical drainage of CSDH may be associated with a shorter LOS, and lower postoperative complications. As most of our included studies were observational in nature, our results should be interpreted as summaries of unadjusted group comparisons. In view of the low certainty of evidence, higher quality evidence is required to corroborate these findings. STUDY REGISTRATION: PROSPERO (CRD42022333388); first submitted 1 June 2022.

RéSUMé: OBJECTIF: La technique anesthésique optimale pour le drainage chirurgical de l'hématome sous-dural chronique (HSDC) demeure incertaine. Nous avons réalisé cette revue systématique et méta-analyse pour déterminer si l'anesthésie locale (AL) avec ou sans sédation ou l'anesthésie générale (AG) entraînait de meilleurs devenirs suite à un drainage chirurgical de l'HSDC. MéTHODE: Nous avons effectué des recherches dans les bases de données PubMed, EMBASE, Scopus, le registre central Cochrane des études contrôlées et ClinicalTrials.gov afin d'en extraire les études randomisées contrôlées (ERC) et les études prospectives ou rétrospectives qui comparaient l'AG à l'AL chez une patientèle adulte bénéficiant d'un drainage chirurgical de l'HSDC et qui rapportaient au moins un résultat d'intérêt. Les critères d'évaluation principaux d'intérêt comprenaient la durée totale de la chirurgie, le taux de récidive et la durée du séjour à l'hôpital. Les critères d'évaluation secondaires comprenaient les événements indésirables peropératoires, les complications postopératoires et la mortalité postopératoire. RéSULTATS: Huit études (1542 patients, 926 AL, 616 AG) ont été incluses, dont deux ERC et six études observationnelles. En regroupant les estimations de toutes les études disponibles, nous avons constaté que l'AL était associée à une diminution de la durée moyenne de séjour d'environ deux jours (intervalle de confiance [IC] à 95 %, −3,47 à −0,77; P = 0,01; faible certitude des données probantes) ainsi qu'à un risque plus faible de complications postopératoires (rapport de cotes, 0,31; IC 95 %, 0,17 à 0,58; P = 0,004; très faible certitude des données probantes). Il n'y avait pas de différence significative en termes de durée de la chirurgie, ni de taux de récidive, d'événements indésirables peropératoires ou de mortalité. La qualité des études observationnelles était médiocre à passable, en grande partie en raison de l'hétérogénéité entre les études. Parmi les ERC, l'une présentait un faible risque de biais et l'autre a été considérée comme présentant un risque élevé de biais. CONCLUSION: L'anesthésie locale avec ou sans sédation pour le drainage chirurgical de l'HSDC peut être associée à une durée de séjour hospitalier plus courte et à des complications postopératoires plus faibles. Étant donné que la plupart des études incluses étaient de nature observationnelle, nos résultats doivent être interprétés comme des résumés de comparaisons de groupes non ajustées. Compte tenu de la faible certitude des données probantes, des données de meilleure qualité sont nécessaires pour corroborer ces conclusions. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022333388); soumis pour la première fois le 1er juin 2022.

Obesity Paradox and Surgical Evacuation for Chronic Subdural Hematoma.

BACKGROUND:  Chronic subdural hematoma (cSDH) has a number of risk factors for recurrence, and some studies suggest obesity is one of them. Yet obesity has been shown to have a positive survival benefit in many diseases such as ischemic stroke, chronic obstructive pulmonary disease, percutaneous coronary intervention, and mechanical thrombectomy. Therefore, we sought to determine if obesity provided a mortality benefit in patients with cSDH undergoing burr hole drainage or craniotomy. METHODS:  We performed a retrospective database analysis using a multi-institutional (TriNetX) database looking at obese versus non-obese patients with cSDH undergoing surgical drainage. Our primary endpoint was mortality. Secondary endpoints included seizure, pulmonary embolism (PE), myocardial infarction (MI), cerebral infarction, deep vein thrombosis (DVT), tracheostomy, and percutaneous endoscopic gastrostomy (PEG). These were looked at to obtain a better idea of prognosis. Cohorts were propensity score-matched for confounders, using the greedy-nearest neighbor algorithm with a caliper of 0.1 pooled standard deviations. Kaplan-Meier survival curves were also developed, and hazard ratios were calculated. Chi-square analysis was performed on categorical variables. RESULTS:  A total of 1,849 patients were identified as obese with a drainage procedure, while 12,371 were identified as non-obese. Some 1,746 patients remained in each group after propensity score matching. Thirty-day survival rates were 88.08% in the obese vs. 83.82% in the non-obese cohorts, 90-day survival 85.15% vs. 79.35%, 365-day survival at 80.89% vs. 71.90%, and five-year survival at 64.75% vs. 54.84% (p < 0.0001). The risk difference was -8.02% (95% confidence interval, Cl -11.02, -5.021%); relative risk, RR 0.757, 95% Cl (0.67, 0.841); odds ratio, OR 0.676 (0.583, 0.783); p < 0.0001). Seizures, ventilator dependence, MI, cerebral infarction, tracheostomy, and PEG rates were all non-significant. Obese patients had a higher rate of PE (7.90% vs. 4.47%, p < 0.0001) and DVTs (12.37% vs. 10.02%, p = 0.0278). CONCLUSIONS:  Obesity in patients with cSDH undergoing surgical evacuation is associated with decreased mortality but higher rates of DVT and PE.