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Clinical investigation of chronic subdural hematoma: Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence
Journal Pre-proof Clinical investigation of chronic subdural hematoma: Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence Roberto Gazzeri, Adrienn Laszlo, Andrea Faiola, Mario Colangeli, Antonio Comberiati, Andrea Bolognini, Giorgio Callovini
PII:
S0303-8467(20)30048-2
DOI:
https://doi.org/10.1016/j.clineuro.2020.105705
Reference:
CLINEU 105705
To appear in:
Clinical Neurology and Neurosurgery
Received Date:
16 August 2019
Revised Date:
7 October 2019
Accepted Date:
29 January 2020
Please cite this article as: Gazzeri R, Laszlo A, Faiola A, Colangeli M, Comberiati A, Bolognini A, Callovini G, Clinical investigation of chronic subdural hematoma: Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence, Clinical Neurology and Neurosurgery (2020), doi: https://doi.org/10.1016/j.clineuro.2020.105705
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
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Clinical
investigation
of
chronic
subdural
hematoma:
Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence. Roberto Gazzeri M.D. (1,2), Adrienn Laszlo M.D.(1), Andrea Faiola M.D.(1), Mario Colangeli M.D.(1), Antonio Comberiati M.D.(1), Andrea Bolognini M.D.(1), Giorgio Callovini M.D.(1) 1) Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome, Italy
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2) Department of Neurosurgery, Istituto Nazionale Tumori „Regina Elena” – IFO, Rome, Italy
Roberto Gazzeri, M.D.
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Department of Neurosurgery
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Address all correspondence:
San Giovanni Addolorata Hospital,
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Via Amba Aradam 9, 00184, Rome, Italy Phone: +39 0677055471
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Fax: +39 0677055356
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Email: [email protected]
1 Highlights
CSDH recurrence does not appear to be affected by surgical technique (craniotomy vs burrhole) Subgaleal drainage techniques are not inferior to the traditional subdural drainage methods Preoperative antiplatelet treatment was predictive of higher recurrence rate. Preoperative anticoagulant medication was an indipendent risk factor for acute postoperative hemorrhage. Choice of surgical procedure and drainage is guided by surgeon preference,radiological features and intraoperative findings
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Abstract
Objectives: Chronic subdural hematoma (CSDH) is one of the most common diseases in the routine neurosurgical practice. The most usual procedures for CSDH treatment
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include single or multiple burr hole drainage craniectomy. There is still controversy, however, about the risks and benefits of the different surgical approaches and types of drainage. The aim of the current study is to evaluate the postoperative complications of
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the various surgical techniques of CSDH.
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Patients and Methods: We conducted a single center retrospective analysis on 414 patients surgically treated for CSDH over a period of 6 years. Comparisons were made after dividing the patients into 4 groups based on the surgical technique and type of drainage:
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Single burr hole with subdural drainage (Group Ia), single burr hole with subgaleal drainage (Group Ib), craniotomy with subdural drainage (Group IIa), and craniotomy with subgaleal drainage (Group IIb). 238 cases underwent burr hole with irrigation, while 290
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cases were treated with craniotomy. Of the analysed patients, subdural drainage was inserted in 382 cases, while subgaleal drain was used only in 146 patients, for a total of
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528 procedures.
Results: Re-operation was performed in 9.47% of cases. The frequency of re-intervention for recurrences appeared to be lower in the Group I a (5.06%), while the frequency of the re-intervention was higher in the craniotomy with subdural drainage group (Group IIa, 11.6%) . 14 patients (2.65%) developed acute subdural rebleeding in the immediate postoperative period with 6 of them on antiplatelets/anticoagulants in the preoperative period.
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Conclusion: Recurrence rate and functional outcome after surgical drainage of CSDH does not appear to be affected by surgical technique (craniotomy vs burrhole) and drainage location. To our opinion, surgeons may elect procedures on a case-by-case basis.
Key Words
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Chronic subdural hematoma, craniectomy, craniotomy, subdural drainage, subgaleal drainage, drain, hemorrhage, recurrence
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Introduction
Chronic subdural hematoma (CSDH) is a frequent disease encountered in daily
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neurosurgical practice [3,5,14,30,38,46] . Predisposing factors, among others, are alcoholism, various coagulopathies and the use of antiplatelet drugs [11,23,28,33,53,55].
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Irrespective to the cause, the source of bleed is commonly the crossing subdural veins, which rupture may lead to the hemorrhage. Although the prognosis of CSDH is reported to be relatively good, several surgical approaches are key part of the treatment. These
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include craniotomy, burr hole with or without subdural closed system drainage, percutaneous tapping and twist drill craniostomy. The clinical results of these procedures depends from the characteristics of patients and the outcomes are largely variable [21].
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Postoperative recurrence of CSDH occurs relatively frequently and is in the focus of neurosurgeons [29]. Recent studies suggest that burr hole drainage is a better technique
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when compared with twist drill craniostomy and craniotomy, and results in lower incidence of recurrent bleeding and other morbidities [31,50]. However, due to the lack of Class I evidences, head to head comparisons of these treatments, the discussion about the best surgical approach is still ongoing [50]. At present, burr hole surgery combined with a subdural closed-drainage system is the most commonly chosen treatment strategy. More recently, enlarged single burr hole trepanation with concomitant use of a suctionassisted subgaleal draining system has also earned consideration as a safe and effective approach. Proponents forperforming a craniotomy emphasize that the wider exposure
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helps for more precise localization of the damage and better placement of the subdural drains, resulting in a decreased recurrence rate [47,52]. There is still a controversy, however, whether or not the use of subdural drainage decreases the incidence of hematoma recurrence. Thus, the optimal treatment is not yet defined and prediction of recurrence is difficult. In our Department, the two surgical procedures currently applied to treat CSDH are burr hole washout and „mini” craniotomy with two different drainage methods, subdural or subgaleal. The aim of this retrospective study is to present recurrence of bleeding and complications rate comparing the different surgical and
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postoperative drainage techniques.
Material and methods
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From September 2011 to September 2017, in the Department of Neurosurgery of San Giovanni – Addolorata Hospital, 414 consecutive adult patients have been surgically
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treated due to symptomatic CSDH. Electronic and paper medical records including operative reports, postoperative images, and postoperative inpatients and outpatients
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progress records were reviewed. We collected the following data: age, gender, ambulatory status, perioperative risk factors, anesthesia, type of the surgical intervention and type of drainage. The primary endpoints of the study included recurrence of bleeding
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and re-operation rates within two months. Secondary endpoints involved the surgical complications (infection rate, post-operative acute hemorrhage and epileptic crisis) and perioperative mortality. All the patients underwent head computed tomographies (CT)
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using identical imaging protocol which consisted of a 512X512 matrix with 5 mm axial slices. Non contrast head CT scans were performed before surgery, at 5-7 days after the
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operation and at 1 month follow up. The side, extent and thickness of hematoma, and the fact of unilaterality or bilaterality were recorded. Clot volume of subdural hematoma was measured using the formula AxBxC/2, where A, B and C represent the dimensions in three axes perpendicular to each other. The preoperative Glasgow Coma Scale score and relevant neurological findings were noted. Routine laboratory analyses before surgery included a complete blood count, platelet count, international normalized ratio (INR), prothrombin time and activated partial thromboplastine time, and biochemical laboratory indices. Preoperative management included medical normalization of the coagulation
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parameters. Any antiplatelet and/or anticoagulant therapy was discontinued at the time of admission and re-established not earlier than 4 weeks after the surgical treatment. In case of coagulopathy, corrective measures included preoperative intravenous (IV) infusion of fresh frozen plasma, Vitamin K and/or platelets. We excluded all patients who had been previously operated and those with insufficient medical records. Patients with missing data sets were excluded if the missing data were relevant to that particular analysis. Subdural hygromas, special clinical cases like calcified or ossified CSDHs (the so-called „armored brain”), asymptomatic CSDHs, and patients without sufficient follow-up data were also not considered for the present
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analysis. Moreover, patients with acute subdural hematomas, defined those within 3 days of injury or CT scan showing an uniformly hyperdense collection, were also excluded. In each cases, surgical techniques were selected on a case to case basis. Comparisons were made after dividing the patients into 4 groups based on the surgical technique and type of
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drainage. Single burr hole with subdural drainage (Group Ia) was performed in 158 cases, while single burr hole with subgaleal drainage (Group Ib) was performed in 80 cases:
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patients who underwent craniotomy with subdural drainage (Group IIa) and craniotomy with subgaleal drainage (Group IIb) were 224 and 66 respectively. The surgical technique for mini-craniotomy involved raising a craniotomy flap of 5-7 cm in greatest diameter
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centered over the area of maximal hematoma thickness. The burr hole craniostomy consisted of a single burr hole enlarged with rounger. Passive drains were used in the
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subdural location, while active suction drains were placed in the subgaleal location, over the burrhole with the dura left partially open. Statistical analyses were performed to evaluate the association of operative variables with the risk of reintervention. Univariate
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analysis was performed using 2-sided Pearson’s chi-square tests; Multivariate analyses were used to asses the impact of variables on outcome. Variables entered into the final
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multivariate analyses were those that were shown to influence the association of interest in univariate analyses, or putative factors for the end points of interest. All statistical analyses were performed using commercial software (IMP II, SAS institute Inc., Cary, NC, USA).
Postoperative Postoperatively, the patients were kept supine for two days to facilitate gravitational drainage of residual subdural fluid, and received hydration 2000cc of IV fluids a day for
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3-4 days to promote expansion of the brain. The patients received also antibiotic medications for 1 postoperative day. At 48-72 hours postsurgery, the draining system was systematically removed, and patients were mobilized as early as possible. If early postoperative anticoagulation was necessary, low molecular weight heparin was administrated. A standardized postoperative physiotherapeutic evaluation determined whether the patient was discharged or transferred to a rehabilitations institution . Antiepileptic prophylaxis was not given routinely to patients. However, it was continued in patients with history of seizures or it was started if the patient had new-onset seizure. In the case of postoperative infection, we differentiated between superficial, thus
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extracranial, infections and deep, subdural or intraparenchymal, infections. Detection of hematoma recurrence was based on a daily neurological examination and was subsequently confirmed by CT scanning. CSDH was considered to have recurred when neurological signs and/or symptoms augmented, reoccured, or did not improve within 1 month of the original primary procedure and the hematoma volume increased. Only
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patients who fulfilled both criteria underwent repeated operation. Residual hematoma into subdural cavity following the first operational procedure without accompanying signs and
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symptoms, and with no mass effect was not recognized as recurrence or as an indication for repeated surgery in this study. In cases of bilateral hematomas, the outcome of both
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hematomas were analysed separately.
Results
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The mean age of the patients was 79.2 years (range 46-97 years) and included 274 men and 140 women. Because 114 patients underwent bilateral operations, we analysed a total
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of 528 operation sites of CSDH. Symptoms and signs
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390 patients (94.2%) had a history of trauma, most of which were minor; transient loss of consciousness or posttraumatic amnesia was recognized in 24 patients (5.8%). The mean interval from head injury to operation was 9 weeks (range 4-15 weeks). The hematoma was located on the left side in 138 cases, on the right side in 162 cases, and bilaterally in 114 patients. The leading initial symptoms were headache (n= 204), hemiparesis (n=274), and deterioration of level of consciousness (n= 118). The demographic and baseline characteristics of the subject population are listed and compared in Table 1. 176 patients
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(42.5%) had coagulopathies: thrombocytopenia caused by leukemia was present in 6 patients, while 160 patients received antiaggregant (n=126) and anticoagulant (n=34) therapy; 10 cases were dialytic patients. A history of head injury was unclear in most patients who presented with associated coagulopathy. Outcome The mean duration of hospitalization was 8 days (range 4-32 days); patients were discharged home or transferred to other phisyotherapic services according to their neurological status. Patients with no complications were usually discharged on the seventh day postsurgery and followed up for at least 2 months as outpatient in our
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Department. Postoperative clinical outcomes between the 4 groups were compared. When hospital days and outcome at discharge (GCS) between the four groups were compared, no statistically significant differences were found. After surgery, follow up CT scans were performed: the mean hematoma thickness decreased from 25.3 mm (range 17-34 mm) to
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7.9 mm (range 4-15 mm). Clot volume of subdural hematoma was measured also using the formula AxBxC/2: the mean pre-operative hematoma volume decreased significantly
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from 96 cm3 (range 13,6 cm3 - 141,4 cm3) to 17 cm3 (range 62 mm3 - 47,8 cm3) during the post-operative period.
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Primary endpoint: symptomatic recurrence requiring surgery For the entire study population, recurrent CSDH on the ipsilateral side requiring repeated
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surgical treatment was detected in 50 patients ( 9.47% ). According to surgical approach, there was no significant difference in recurrence rates between patients having burrholes (3.41%) or craniotomy (6.06%) (p=0.401) when controlling for other variables.
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According to drainage location, recurrence occurred in 16 cases (3,03%) in subgaleal drainage patients, while in 34 cases (6.44%) in subdural drainage cases. There were 1.5%
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of recurrence in Group Ia, while 1.9% in Group Ib; in Group IIa 6.3% of all the cases underwent reoperation for recurrence of the hematoma, while only 1.1% of recurrences were treated in Group IIb. Multivariate analyses revealed that, when adjusting for variables affecting recurrence rate, the between group statistical differences did not reach the level of significance. Recurrence was found in 36 cases (12%) of unilateral hematomas, while in 14 cases (12.2%) in bilateral CSDHs. None of the demographic, clinical, or radiological features correlated with postoperative recurrence except the use of preoperative antiplatelet therapy.
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Of the patients taking antiaggregants , 108/126 received a transfusion of platelets preoperatively, while 18 cases discontinued their medication for the traditional 7 days. For patients taking warfarin, reversal treatment was vitamin K associated to transfusion of plasma (19 cases) or clotting factors (15 cases). Recurrence occurred in 21.4% of 126 patients on antiplatelets (102 aspirin/ 24 clopidogrel) therapy and in 11.7% of 34 cases on anticoagulant (warfarin) therapy, while recurrence rate in patients with no antiplatelet/antiaggregant therapy was 5.9% (p=0.017). Furthermore, 2 dialytic patients underwent new operation for CSDH recurrence. The interval from the first operation to the reoperation ranged from 1 to 7 weeks.
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Secondary Endpoints: Complications Excluding recurrences, reoperation for complications was performed in 4.2% of cases and it was primarily due to acute hemorrhages. The frequency of re-intervention appeared to be lower in the burrhole group, while was higher in the craniotomy with subdural drainage
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group (5,3%) and in the craniotomy with subgaleal drainage group (6%). The overall group differences, however, did not reach the level of statistical significance (p=0.184).
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Postoperative acute hematoma occurred in 3.3% of patients with preoperative unilateral
hematoma, while it occurred in 3.5% of bilateral hematomas: the difference was not statistically significant. Postoperative complications related to the surgical intervention
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are summarized in Table 2 and 3. Infection occurred in 2.9% of patients. 4 patients with superficial wound infection underwent superficial wound revision in addition to
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intravenous antibiotic therapy. In 6 cases, deep infection was surgically evacuated. Symptomatic postoperative pneumocephalus needing surgical revision was seen in 4 cases (0.76%): 2 cases in group IIa and the other two in Group IIb. New-onset seizures
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were seen in 12 patients with subdural drainage in the postoperative period. In 8 cases the subdural drainage was in contact with the cortical surface of the brain and was removed
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with immediate resolution of the symptoms, while 4 patients had partial motor seizures that were managed successfully by the application of anticonvulsant drugs. CT scans of the patients with new-onset seizures in Group IIb revealed acute subdural hematoma with specks of pneumocephalus. There were no significant statistical differences in seizures between the two drainage groups. 14 patients (2.65%) developed acute subdural rebleeding in
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immediate postoperative period.
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of them
were on
antiplatelets/anticoagulants in the preoperative period; higher incidence of postoperative hemorrhagic complications were observed in the patients on anticoagulant therapy
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(17.6%) compared to the group on antiplatelets therapy (4.8%) and no coagulopathy group (0.8%) (p=0.019). Of these patients, all underwent craniotomy under general anesthesia and evacuation of the present blood clots. Intracerebral hemorrhage was observed in 4 patients (2 in Group Ia and 2 in Group IIa). Perioperative mortality rates within 30 days after surgery was 1.52 % of total cases (2.5%of Group Ia and 1.8% of Group IIa). Causes of death included development of acute subdural hematoma after surgery in 4 cases, while the other 4 patients arrived to our emergency room unconscious and died with no improvement after surgery.
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Discussion In this population based study of patients with chronic subdural hematoma treated with four different treatment regimens, we didn’t find any difference in recurrence between groups. However, the use of preoperative antiplatelets therapy was associated to a higher
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incidence of recurrence, while preoperative anticoagulant therapy was a significant risk factor for postoperative acute subdural hemorrhage. Surgical Approach
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According to experience and preference of the surgeons and to the radiological appearance of the subdural hematoma, we performed 2 different surgical procedures: burr
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hole and „mini” craniotomy. Burr hole craniostomy is the most commonly procedure performed in the treatment of CSDH within the last 20 years. It is a simple and widely practised technique with a recurrence rate of 0-28% and an overall morbidity of 0,9%
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[1,3,5,14,24,39,51,54]. Recurrence of CSDH after the first burr hole craniostomy is not rare, with a reported incidence of 7-18% [13,23,34,36]. Craniotomy is reported to be the way of surgical treatment with the least risk of recurrence, but has a greater related
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morbidity and mortality: this because in the series of craniotomy are included patients probably with higher risk of recurrence or had worse preoperative status [12,43]. In our
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study, we performed craniotomy in 232 cases. Recurrence are statistically significant in multilocular collections:
analysing the factors that can predict recurrence of the
hematomas, the laminar separated type of CSDH have a statistically significant correlation with the recurrence of the hematomas [7]. In our series, the choice of the type of procedure was related to CT findings on admission; non-liquefied hematomas with multilayer loculations with a web- or net-like structure, multiple compartments, mostly septated, underwent craniotomy and membranectomy. In view of high recurrences for multilocular hematomas, in these subtypes burr hole craniostomy appeared to be not
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adequate to intercept and drain all the multiloculations of the hematoma, thus we performed a craniotomy [7]. Furthermore, we preferred craniotomy in cases of mixed density subdural collection because hyperdense material was easier to remove using this surgical approach. Drainage following surgical evacuation of the subdural hematoma results in better outcome [23,49]. Most surgical strategies include the use of a draining system with the catheter tip inserted into the subdural space. The use of a subdural drain associated to burr hole craniectomy increases drainage volume and lowers the risk of recurrence of the subdural hematoma [23]. A comprehensive evidence-based systematic review comparing several randomized controlled trials about surgical treatment for
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chronic subdural hematomas involving more than 1900 patients was performed by Ivamoto et al.: the recurrence rate between the drainage group (5% of recurrences) and the group without drainage (33% of recurrences) was statistically significant (P<0,01) [23] . In their prospective multicenter study, Glancz et al. specified that position of drain did not appear to influence recurrence rate of the subdural hematoma (subdural drain
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7.7% vs subgaleal drainage 9.1%)[19]. Sjavik et al. observed higher recurrence rate in the subdural drain group compared to subgaleal drainage cohort, implying an inadequate
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evacuation of the subdural hematoma in the former group[44]. In our cases, the choice of subdural vs subgaleal drain was selected intraoperatively; the subgaleal drainage was
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preferred in cases of rapid brain expansion after CSDH evacuation, while subdural drain was inserted in those cases of atrophic brain or large subdural areas. The subdural drainage was inserted in the frontal subdural space in most of the patients whose brain
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did not re-expand at the end of the drainage procedure. In our experience, the insertion of the drain under the galea is particularly trouble-free, because no manipulation of intracranial structures is necessary with limited risk of intracranial hemorrhage. In a
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prospective randomized study performed by Kaliaperumal et al., subgaleal drainage and subdural drainage were compared in 50 patients following burr hole: no significant
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differences were detected [26]. Gazzeri et al. published a large series on subgaleal drain through a „mini” craniotomy reporting 7.6% hematoma recurrence, a finding comparable to our current cohort of subgaleal drain associated to craniotomy (9.4%). In a retrospective single-center study, Zumofen et al. analyzed the results of all patients following double burr hole trepanation using a subperiostal passive closed-drainage system [55]. Hematoma persistence or recurrence occurred in 13.1% of the cases. In contrast to our cohort of subgaleal drainage, the choice of a double burr hole strategy allowed Zumofen et al. to abstain from active perioperative draining methods and to avoid
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enlargement of the burr holes [55]. In the literature, reintervention rates after burr hole surgery with subdural drains vary between 8.3% and 26.5% [2,8, 13,22,35]. Results from the series with subgaleal drainage reported by Gazzeri et al. [17] with a reoperation rate of 7.6%, represent comparatively low incidences of recurrence. In the study of Bellut et al. comparing subdural vs subgaleal drainage methods, there were no statistically significant differences regarding postoperative hematoma remnants, rates of recurrences, mortality, and complications, between the groups [4]. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage
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system. Our data strongly suggest that subgaleal drainage techniques are not inferior to the traditional subdural drainage methods. Recent studies reported that there were no differences in perioperative morbidity between general and local anesthesia; also in our series, general anesthesia was not associated with higher morbidity and recurrence rate.
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Recurrence
Although chronic subdural hematoma is a well known curable disease in the aging
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population, the rate of reoperation is reported to be high, between 2.7 and 33% [10,20,42,44,47]. Postoperative recurrence of CSDH is not rare and has always been a
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source of frustration for neurosurgeons [18,29,32]. Prevention of hematoma recurrence and reduction of postoperative hygroma formation results not only from efficient hematoma drainage, but also depends on postoperative management that actively
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promotes adequate brain re-expansion [15,16,37,48]. Therefore, we advocate a significant period of flat bed rest in combination with mild intravenous hyperhydration, although there is contradictory advice about the risks and benefits of postoperative early
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mobilization versus bed rest [6]. The recurrence rate and the bad outcome of CSDH are higher in patients with greater width of hematoma, cerebral atrophy, and significant
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subdural air accumulation. Our decision to proceed with revision surgery was based on clinical symptoms correlated with imaging. In our series, we found only 8 cases (5%) of recurrence in the burr hole with subdural drainage group, while there were 10 (12.5%) in Group Ib; looking at recurrences in the cranitomies group, in Group IIa 11.6% of cases underwent reoperation for recurrence, while 9.4% of hematoma recurrences were treated in Group IIb. Although Brennan et al. reported that the preoperative prescription of antiplatelet agents was not an independent independent factor for recurrence in their series, antiplatelet and anticoagulant medications have been implicated in the
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development ad recurrence of CSDH [6]. In the current study, the preoperative prescription of antiplatelets therapy was a statistically significant risk factor for recurrence. Acute subdural/epidural and intracerebral hemorrhage Postoperative acute intracerebral hemorrhage was reported in some series in association with the use of subdural drain and burr hole techniques [27]. Gazzeri et al.and Zumofen et al. have signified that the use of a subdural drain with burr hole may lead to intracerebral hemorrhage. These drainage catheters may penetrate into the brain parenchyma or injure bridging veins. In our current series, in all 4 cases of intracerebral
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hemorrhage a subdural drain was used. Reoperation secondary to acute hemorrhage was performed in 7 cases: in 6 of these, a subdural drainage was used. The use of anticoagulant agents was observed to be significantly associated with postoperative acute subdural
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hematoma (p=0.019) when controlling for other variables. Pneumocephalus
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Massive postoperative pneumocephalus is one of the main factors complicating the adhesion of the inner and outer membrane, thus it induces a postoperative reaccumulation
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of chronic subdural hematoma [36 ]. Symptomatic pneumocephalus has been reported to range from 0 to 10% in literature.
In our study, symptomatic postoperative
Epilepsy
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pneumocephalus was seen in 4 cases (0.8%): all the cases were in the craniotomy groups.
Postoperative seizure in CSDH is reported to occur in 7% to 13.7% of cases [9, 41 ]. In
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the study of Zumofen, in which subgaleal drainage was used, postoperative seizure was noted in 8.2% of patients [55]. This comparatively low incidence may corroborate the
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theory reported by Gazzeri et al. [17 ] stipulating that the absence of an irritating subdural drain in direct contact with the cortical surface of the brain and the hematoma capsule, moderates the risk of seizure during the phase of brain re-expansion. In this study we didn’t observe significant differences in seizures between patients having subdural or subgaleal drain (p=0.359). There were new-onset seizures in 14 patients (3.4%): 12 patients had a subdural drainage in contact with the cortical surface of the brain, which was immediately removed, while 2 patients had partial motor seizures that were managed successfully with anticonvulsant drugs.
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Infection One cited complication for subdural drain is empyema, occurring in 2,1% of postoperative patients [41]. Gazzeri et al. [17] reported a very low incidence of postoperative deep infection in relation with extra-cranial placement of drain. The absence of foreign material in direct contact with intracranial structures possibly limits the propagation of infection agents into deep compartments, potentially moderating the formation of secondary empyema. In our study we had a low incidence of patients with empyema (8 cases), with the infection localized in the sudural space: in six cases the patients had a subdural drainage, while only in two cases had a subgaleal drainage.
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Although infection rate was higher in patients with subdural drain, it was not statistically significant. Mortality
Mortality varies in recent series from 1,2 to 4,3%; coagulopathy, respiratory and cardiovascular complications in elderly patients and poor preoperative neurological status
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are contributory causes of postoperative death [34,40]. The only factor that has a statistically significant correlation with outcome is preoperative neurologic grade. In our
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current series the mortality rate was 1.52%. There are some limitations to our study. First, limitations inherent to retrospective assessment are present in this study, but the clinical
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relevance of recurrence and complications remain incontestable. Second, a major bias is that interventions were not chosen randomly, but each surgeon performed a different surgical approach deciding on a case to case basis. Another limitation is that no
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assessment for seizures by EEG was performed. Further, the question of postoperative drain duration was not assessed in our study. Conclusions
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Recurrence rate and functional outcome after surgical drainage of CSDH does not appear to be affected by surgical technique (craniotomy vs burrhole) and drainage location.
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Preoperative antiplatelet treatment was predictive of higher recurrence rate, while preoperative anticoagulant medication was an independent risk factor for acute postoperative hemorrhage. To our opinion, choice of surgical procedure and type of drainage has to be guided by surgeon preference and intraoperative findings. In cases of septated hematomas, with multilayer loculations, we preferred to perform a „mini” craniotomy. We selected subgaleal drain in cases of rapid brain expansion, while we inserted subdural drainage in cases of atrophic brain. These findings suggest that surgeons may elect procedures on a case-by-case basis, but variations in practice may not influence
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outcomes. Further prospective randomized studies are required to determine whether standardization of surgical management can improve patients outcome.
We would like to thank Simona Matarrese e Serena Bellisari for their invaluable support in data collection. Funding-No funding was received for this research.
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Conflict of Interest: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. “For this type of study formal consent is not required.”
Conflict of interest and disclosures: none.
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There is not any kind of commercial interest in connection with the submitted article
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12. Ducruet AF, Grobelny BT, Zacharia BE, Hickman ZL, DeRosa PL, Andersen KN, Sussman E, Carpenter A, Connolly ES Jr. The surgical management of chronic subdural hematoma. Neurosurg Rev ( 2012)35: 155-169 13. Ernestus RI, Beldzinski P, Lanfermann H. Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol (1997) 48:220–5. 14. Foelholm R, Waltimo O Epidemilogy of chronic subdural haematoma. Acta Neurochir (Wien) (1975) 32:247-250, 15. Fujisawa H, Nomura S, Tsuchida E, Ito H. Serum protein exudation in chronic subdural haematomas: A mechanism for haematoma enlargement? Acta neurochir (Wien); (1998) 140:161-5
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20. Goto H, Ishikawa O, Nomura M, Tanaka K, Nomura S, Maeda K Magnetic resonance imaging findings predict the recurrence of chronic subdural hematoma. Neurol Med Chir (Tokyo) (2015)55(2):173-8.
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24. Iwabuchi T, Sekiya T, Suzuki S. Neurosurgical aspects of the parietal boss in patients with chronic subdural hematomas. Neurosurgery (1981) 9:531–4.
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25. Kaczmarczyk R, Osuchowski J, Trojanowski T, Turowski K, Rakowski P Early results of surgical treatment of chronic subdural hematoma in CT images. Neurol Neurochir Pol. (1994) 2 8:693-701.
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26. Kaliaperumal C, Khalil A, Fenton E, Okafo U, Kaar G, O'Sullivan M, Marks C. A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma. Acta Neurochir (Wien). (2012);154(11):2083-8. 27. Kawamata T, Takeshita M, Kubo O, Izawa M, Kagawa M, Takakura K Management of intracranial hemorrhage associated with anticoagulant therapy. Surg Neurol (1995) 44: 438-443 28. Kim DH, Park ES, Kim MS, Park SH, Park JB, Kwon SC, Lyo IU, Sim HB Correlation between head trauma and outcome of chronic subdural hematoma Korean J Neurotrauma (2016) 12(2):94-100
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29. Kostanian V, Choi JC, Liker MA, Go JL, Zee CS Compured tomographic charecteristics of chronic subdural hematomas. Neurosurg Clin N Am. (2000) 11:479-89 30. Kudo H, Kuwamura K, Izawa l, Sawa H, Tamaki N Chronic subdural hematoma in elderly people: present status on Awaji lsland and epidemiological prospect. Neurol Med Chir (Tokyo) (1992) 32: 207-209 31. Lega BC, Danish SF, Malhotra NR, Sonnad SS, Stein SC Choosing the best operation for chronic subdural hematoma: a decision analysis. J Neurosurg (2012) 113: 615-621 32. Leroy HA, Aboukais R, Reyns N, Bourgeois P, Labreuche J, Duhamel A, Lejeune JP. Predictors of functional outcomes and recurrence of chronic subdural hematomas. J Clin Neurosci (2015) 22: 1895-1900
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33. Macfarlane MR, Weerakkody Y, Kathiravel Y Chronic subdural haematomas are common on left than ont he right. J Clin Neurosci (2009) 16: 642-644,. 34. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications and recurrence rate. Neurol Med Chir (Tokyo) (2001) 41:371-81.
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35. Nakaguchi H, Tanishima T, Yoshimasu N Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage. J Neurosurg (2000) 93:791–5
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36. Nakaguchi H, Tanishima T, Yoshimasu N Factors int he natural history of chronic subdural hematomas that influence their postoperative recurrence. J Neurosurg. (2001) 95:256-62.
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37. Oishi M, Toyama M, Tamatani S, Kitazawa T, Saito M. Clinical factors of recurrent chronic subdural hematoma. Neurol Med Chir (Tokyo) (2001) 41:382-6
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38. Ooba S, Shiomi N, Shigemori M [Clinical features and surgical results of chronic subdural hematoma in extremely aged patients]. No Shinkei Geka (2006) 34: 273-278, (Japanese)
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39. Oral S, Borklu RE, Kucuk A, Ulutabanca H, Selcuklu A. Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma North Clin Istanbul (2015) 2(2):115-121
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40. Ro HW, Park SK, Jang DK, Yoon WS, Jang KS, Han YM Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma. Acta Neurochir (Wien) (2016) 158:135-139 41. Rohde V, Graf G, Hassler W. Complications of burr-hole craniostomy and closedsystem drainage for chronic subdural hematomas: a retrospective analysis of 376 patients. Neurosurg Rev. (2002) 25: 89-94 42. Rust T, Kiemer N, Erasmus A Chronic subdural haematomas and anticoagulation or anti-thrombotic therapy. J Clin Neurosci (2006) 13: 823-827 43. Shofty B, Grossman R Treatment options for chronic subdural hematoma. World Neurosurg (2016) 87: 529-530
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44. Sjåvik K, Bartek J Jr, Sagberg LM, Henriksen ML, Gulati S, Ståhl FL, Kristiansson H, Solheim O, Förander P, Jakola AS. Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study.J Neurosurg. 2017 Jun 23:1-7. doi: 10.3171/2016.12.JNS161713. 45. Tokmak M, Iplicioglu AC, Bek s, Gökduman CA, Erdal M The role of exudation in chronic subdural hematomas. J Neurosurg. (2007)107:290-5. 46. Toi H, Kinoshita K, Hirai S, Takai H, Hara K, Matsushita N, Matsubara S, Otani M, Muramatsu K, Matsuda S, Fushimi K, Uno M. Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database. J Neurosurg. (2017) 128(1):222-228
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47. Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M, et al. Indipendent predictors for recurrence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery (2008) 63: 1125-1129 48. van Havenbergh T, van Calenbergh F, Goffin J, Plets C Outcome of chronic subdural haematoma: analysis of prognostic factors. Br J Neurosurg (1996)10:35–9.
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49. Wakai S, Hashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M. Efficacy of closedsystem drainage in treating chronic subdural hematoma: a prospective comparative study. Neurosurgery (1990) 26:771–3.
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50. Weigel R. Schmiedek P, Krauss JK Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurosurg Psychiatry (2003) 74: 937-943.
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51. Weisse A, Berney J Chronic subdural haematomas. Results of a closed drainage method in adults. Acta Neurochir (1994) 127:37–40. 52. White M, Mathieson CS, Campbell E, Lindsay KW, Murray L Treatment of chronic subdural haematomas – a retrospective comparison of minicraniectomy versus burrhole drainage. Br J Neurosurg (2010) 24: 257-260
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53. Yasuda CL, Morita ME, Nishimori FY, Yasuda AM, Alves HL Chronic subdural hematoma: study of 161 patients and the relationship with coagulation abnormalities. Arq Neuropsiquiatr (2003)61: 1011-1014
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54. Yoshimoto Y, Kwak S Frontal small craniostomy and irrigation for treatment of chronic subdural haematoma. (1997) Br J Neurosurg;11:150–1
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55. Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery(2009) 64:1116-22
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Group IIA 204 (54,2%) 224 (42,4%)
Group IIB 52 (12,5%) 66 (12,5%)
274 / 140
64/44
37/13
141/63
32/20
0.128
76,3
74,9
76,3
76,4
77,2
0.188
Side of the haematoma (%) Right Left Bilateral
162 (39%) 138 (33,5%) 114 (27,5%)
48 (44,4%) 10 (9,3%) 50 (46,3%)
10(20%) 12(22%) 30(58%)
91(44,2%) 93(46%) 20(9,8%)
13(25%) 25(48%) 14(27%)
0.342 0.282 0.696
Location ( %) Frontal Fronto-parietal Parietal Fronto-parietooccipital
38(7,2%) 358(67,8%) 28(5,3%) 104(19,7%)
9(5,7%) 97(61,4%) 11(7%) 41(25,9%)
5(6,3%) 46(57,5%) 0(0%) 29(36,2%)
19(8,5%) 179(79,9%) 7(3,1%) 19(8,5%)
5(7,6%) 36(54,5%) 10(15,2%) 15(22,7%)
0.166 0.205 0.475 0.386
22(9,8%) 16(7,8%) 114(55,8%) 17(8,3%) 56(27,4%) 24(11,7%)
3(5,7%) 5(9,6%) 32(61,5%) 4(7,7%) 24(46,1%) 4(7,7%)
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14(12,9%) 13(12%) 58(53,7%) 16(14,8%) 44(40,7%) 21(19,4%)
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44 (10,6%) 39 (9,4%) 230 (55,5%) 41(9,9%) 144(34,7%) 58 (14%)
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Comorbidities (%) Dementia Ischemic Heart disease Arterial hypertension Arrhythmia Diabetes-mellitus Cerebrovascular Disease
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Mean Age yrs
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Gender M/F
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Total patients Total of Surgical Procedures (%)
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Group IB 50 (12,1%) 80 (15,2%)
P-value
414 528
Group IA 108 (26,2%) 158 (29,9%)
5 (10%) 5 (10%) 26 (52%) 4(8%) 20(40%) 7(14%)
0.465 0.401 0.576 0.335 0.166 0.286
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Coagulopathies (%) Antiplatelet Medications Warfarin Others
32(29,6%) 9(8,3%) 4(3,7%)
16(32%) 4(8%) 1(2%)
66(32,3%) 17(15,6%) 83,9%)
12(23%) 4(7,6%) 3(5,7%)
0.342 0.181 0.057
290 (70%) 124 (30%)
46(42,5%) 62(57,5%)
19(38%) 33(62%)
179(87,7%) 23(12,3%)
46(88,4%) 6(11,6%)
0.485 0.628
Mean preoperative GCS Score
13,7
13,7
13,9
13,7
13,8
0.282
Mean GCS Score at F.U.
14,2
14
14,6
14,2
14,5
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Anestesia (%) General Local
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126(30,4%) 34(8,2%) 16(3,8%)
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Table 1. Demographic data and baseline characteristics of the subject population
0.418
Group IA
Group IB
Group IIA
Group IIB
Total
Approaches Recurrence
158 8(5.06%)
80 10 (12.5%)
224 26 (11.6%)
66 6 (9.1%)
Reoperation for complications Deep Infection Acute Hemorrhage (Epi- or Subdural) Brain Hemorrhage Tension Pneumocephal us Epileptic crisis
4(2.5%)
2(2.5%)
12 (5.3%)
4 (6%)
528 50 (9.47%) 22(4.2%)
2 (1.27%) 2 (1.27%)
2 (2.5%) 0
4 (1.8%) 10 (4.46%)
0 2 (3.03%)
8(1.52%) 14 (2.65%)
2 (1.27%)
0
2 (0.89%)
0
0
0
2 (0.89%)
2 (3.03%)
6 (3.8%)
0
6 (2.68%)
2 (3.03%)
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P value between all groups’
P value between groups I (A+B) and II (A+B)
0.420
0.401
0.184
0.101
0.836 0.373
1.000 0.133
Death
4 (2.53%)
0
4 (1.8%)
0
0.836
1.000
4 (0.76%)
0.361
0.503
14(2.65% ) 8 (1.52%)
0.680
1.000
0.631
1.000
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4(0.76%)
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Table 2. Complications in 414 cases, for a total of 528 approaches (114 hematomas were bilateral)
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Group IA: Burr hole and subdural drainage; Group IB: Burr hole and subgaleal drainage; Group IIA: Craniotomy and subdural drainage; Group IIB: Craniotomy and subgaleal drainage. (Pearson’s chi-square test, 2-sided test)
Craniotomy
P value between groups I (A+B) Burrhole and II (A+B) Craniotomy
Subdural drain
Subgaleal drain
238 18 (7.5%) 6 (2.5%)
290 32 (11%) 16 (5.5%)
0.870 0.401 0.101
382 34 (8.9%) 16 (4.1%)
146 16 (10.9%) 6 (4.1%)
P value between all groups IA –IIA (subdural drain) And IB-IIB (subgaleal drain) 0.266 0.647 1.000
4 (1.6%) 2 (0.8%)
4 (1.3%) 12 (4.1%)
1.000 0.133
6 (1.6%) 12 (3.2%)
2 (1.4%) 2 (1.4%)
1.000 0.433
2 (0.8%)
2 (0.6%)
1.000
4 (1%)
0
0
4 (1.3%)
0.503
2 (0.5%)
2 (1.4%)
6 (2.5%) 4 (1.6%)
8 (2.7%) 4 (1.3%)
1.000 1.000
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Approaches Recurrence Reoperation for complications Deep Infection Acute Hemorrhage (Epi- or Subdural) Brain Hemorrhage Tension Pneumocephal us Epileptic crisis Death
Burrhole
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19
12 (3.2%) 8 (2.1%)
2 (1.4%) 0
0.653
0.359 0.546
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Table 3. Complications in 414 cases, comparing treatment characteristics: burrholes vs craniotomies and subdural vs subgaleal drainages
PII:
S0303-8467(20)30048-2
DOI:
https://doi.org/10.1016/j.clineuro.2020.105705
Reference:
CLINEU 105705
To appear in:
Clinical Neurology and Neurosurgery
Received Date:
16 August 2019
Revised Date:
7 October 2019
Accepted Date:
29 January 2020
Please cite this article as: Gazzeri R, Laszlo A, Faiola A, Colangeli M, Comberiati A, Bolognini A, Callovini G, Clinical investigation of chronic subdural hematoma: Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence, Clinical Neurology and Neurosurgery (2020), doi: https://doi.org/10.1016/j.clineuro.2020.105705
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
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Clinical
investigation
of
chronic
subdural
hematoma:
Relationship between surgical approach, drainage location, use of antithrombotic drugs and postoperative recurrence. Roberto Gazzeri M.D. (1,2), Adrienn Laszlo M.D.(1), Andrea Faiola M.D.(1), Mario Colangeli M.D.(1), Antonio Comberiati M.D.(1), Andrea Bolognini M.D.(1), Giorgio Callovini M.D.(1) 1) Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome, Italy
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2) Department of Neurosurgery, Istituto Nazionale Tumori „Regina Elena” – IFO, Rome, Italy
Roberto Gazzeri, M.D.
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Department of Neurosurgery
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Address all correspondence:
San Giovanni Addolorata Hospital,
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Via Amba Aradam 9, 00184, Rome, Italy Phone: +39 0677055471
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Fax: +39 0677055356
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Email: [email protected]
1 Highlights
CSDH recurrence does not appear to be affected by surgical technique (craniotomy vs burrhole) Subgaleal drainage techniques are not inferior to the traditional subdural drainage methods Preoperative antiplatelet treatment was predictive of higher recurrence rate. Preoperative anticoagulant medication was an indipendent risk factor for acute postoperative hemorrhage. Choice of surgical procedure and drainage is guided by surgeon preference,radiological features and intraoperative findings
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Abstract
Objectives: Chronic subdural hematoma (CSDH) is one of the most common diseases in the routine neurosurgical practice. The most usual procedures for CSDH treatment
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include single or multiple burr hole drainage craniectomy. There is still controversy, however, about the risks and benefits of the different surgical approaches and types of drainage. The aim of the current study is to evaluate the postoperative complications of
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the various surgical techniques of CSDH.
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Patients and Methods: We conducted a single center retrospective analysis on 414 patients surgically treated for CSDH over a period of 6 years. Comparisons were made after dividing the patients into 4 groups based on the surgical technique and type of drainage:
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Single burr hole with subdural drainage (Group Ia), single burr hole with subgaleal drainage (Group Ib), craniotomy with subdural drainage (Group IIa), and craniotomy with subgaleal drainage (Group IIb). 238 cases underwent burr hole with irrigation, while 290
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cases were treated with craniotomy. Of the analysed patients, subdural drainage was inserted in 382 cases, while subgaleal drain was used only in 146 patients, for a total of
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528 procedures.
Results: Re-operation was performed in 9.47% of cases. The frequency of re-intervention for recurrences appeared to be lower in the Group I a (5.06%), while the frequency of the re-intervention was higher in the craniotomy with subdural drainage group (Group IIa, 11.6%) . 14 patients (2.65%) developed acute subdural rebleeding in the immediate postoperative period with 6 of them on antiplatelets/anticoagulants in the preoperative period.
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Conclusion: Recurrence rate and functional outcome after surgical drainage of CSDH does not appear to be affected by surgical technique (craniotomy vs burrhole) and drainage location. To our opinion, surgeons may elect procedures on a case-by-case basis.
Key Words
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Chronic subdural hematoma, craniectomy, craniotomy, subdural drainage, subgaleal drainage, drain, hemorrhage, recurrence
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Introduction
Chronic subdural hematoma (CSDH) is a frequent disease encountered in daily
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neurosurgical practice [3,5,14,30,38,46] . Predisposing factors, among others, are alcoholism, various coagulopathies and the use of antiplatelet drugs [11,23,28,33,53,55].
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Irrespective to the cause, the source of bleed is commonly the crossing subdural veins, which rupture may lead to the hemorrhage. Although the prognosis of CSDH is reported to be relatively good, several surgical approaches are key part of the treatment. These
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include craniotomy, burr hole with or without subdural closed system drainage, percutaneous tapping and twist drill craniostomy. The clinical results of these procedures depends from the characteristics of patients and the outcomes are largely variable [21].
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Postoperative recurrence of CSDH occurs relatively frequently and is in the focus of neurosurgeons [29]. Recent studies suggest that burr hole drainage is a better technique
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when compared with twist drill craniostomy and craniotomy, and results in lower incidence of recurrent bleeding and other morbidities [31,50]. However, due to the lack of Class I evidences, head to head comparisons of these treatments, the discussion about the best surgical approach is still ongoing [50]. At present, burr hole surgery combined with a subdural closed-drainage system is the most commonly chosen treatment strategy. More recently, enlarged single burr hole trepanation with concomitant use of a suctionassisted subgaleal draining system has also earned consideration as a safe and effective approach. Proponents forperforming a craniotomy emphasize that the wider exposure
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helps for more precise localization of the damage and better placement of the subdural drains, resulting in a decreased recurrence rate [47,52]. There is still a controversy, however, whether or not the use of subdural drainage decreases the incidence of hematoma recurrence. Thus, the optimal treatment is not yet defined and prediction of recurrence is difficult. In our Department, the two surgical procedures currently applied to treat CSDH are burr hole washout and „mini” craniotomy with two different drainage methods, subdural or subgaleal. The aim of this retrospective study is to present recurrence of bleeding and complications rate comparing the different surgical and
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postoperative drainage techniques.
Material and methods
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From September 2011 to September 2017, in the Department of Neurosurgery of San Giovanni – Addolorata Hospital, 414 consecutive adult patients have been surgically
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treated due to symptomatic CSDH. Electronic and paper medical records including operative reports, postoperative images, and postoperative inpatients and outpatients
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progress records were reviewed. We collected the following data: age, gender, ambulatory status, perioperative risk factors, anesthesia, type of the surgical intervention and type of drainage. The primary endpoints of the study included recurrence of bleeding
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and re-operation rates within two months. Secondary endpoints involved the surgical complications (infection rate, post-operative acute hemorrhage and epileptic crisis) and perioperative mortality. All the patients underwent head computed tomographies (CT)
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using identical imaging protocol which consisted of a 512X512 matrix with 5 mm axial slices. Non contrast head CT scans were performed before surgery, at 5-7 days after the
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operation and at 1 month follow up. The side, extent and thickness of hematoma, and the fact of unilaterality or bilaterality were recorded. Clot volume of subdural hematoma was measured using the formula AxBxC/2, where A, B and C represent the dimensions in three axes perpendicular to each other. The preoperative Glasgow Coma Scale score and relevant neurological findings were noted. Routine laboratory analyses before surgery included a complete blood count, platelet count, international normalized ratio (INR), prothrombin time and activated partial thromboplastine time, and biochemical laboratory indices. Preoperative management included medical normalization of the coagulation
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parameters. Any antiplatelet and/or anticoagulant therapy was discontinued at the time of admission and re-established not earlier than 4 weeks after the surgical treatment. In case of coagulopathy, corrective measures included preoperative intravenous (IV) infusion of fresh frozen plasma, Vitamin K and/or platelets. We excluded all patients who had been previously operated and those with insufficient medical records. Patients with missing data sets were excluded if the missing data were relevant to that particular analysis. Subdural hygromas, special clinical cases like calcified or ossified CSDHs (the so-called „armored brain”), asymptomatic CSDHs, and patients without sufficient follow-up data were also not considered for the present
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analysis. Moreover, patients with acute subdural hematomas, defined those within 3 days of injury or CT scan showing an uniformly hyperdense collection, were also excluded. In each cases, surgical techniques were selected on a case to case basis. Comparisons were made after dividing the patients into 4 groups based on the surgical technique and type of
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drainage. Single burr hole with subdural drainage (Group Ia) was performed in 158 cases, while single burr hole with subgaleal drainage (Group Ib) was performed in 80 cases:
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patients who underwent craniotomy with subdural drainage (Group IIa) and craniotomy with subgaleal drainage (Group IIb) were 224 and 66 respectively. The surgical technique for mini-craniotomy involved raising a craniotomy flap of 5-7 cm in greatest diameter
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centered over the area of maximal hematoma thickness. The burr hole craniostomy consisted of a single burr hole enlarged with rounger. Passive drains were used in the
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subdural location, while active suction drains were placed in the subgaleal location, over the burrhole with the dura left partially open. Statistical analyses were performed to evaluate the association of operative variables with the risk of reintervention. Univariate
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analysis was performed using 2-sided Pearson’s chi-square tests; Multivariate analyses were used to asses the impact of variables on outcome. Variables entered into the final
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multivariate analyses were those that were shown to influence the association of interest in univariate analyses, or putative factors for the end points of interest. All statistical analyses were performed using commercial software (IMP II, SAS institute Inc., Cary, NC, USA).
Postoperative Postoperatively, the patients were kept supine for two days to facilitate gravitational drainage of residual subdural fluid, and received hydration 2000cc of IV fluids a day for
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3-4 days to promote expansion of the brain. The patients received also antibiotic medications for 1 postoperative day. At 48-72 hours postsurgery, the draining system was systematically removed, and patients were mobilized as early as possible. If early postoperative anticoagulation was necessary, low molecular weight heparin was administrated. A standardized postoperative physiotherapeutic evaluation determined whether the patient was discharged or transferred to a rehabilitations institution . Antiepileptic prophylaxis was not given routinely to patients. However, it was continued in patients with history of seizures or it was started if the patient had new-onset seizure. In the case of postoperative infection, we differentiated between superficial, thus
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extracranial, infections and deep, subdural or intraparenchymal, infections. Detection of hematoma recurrence was based on a daily neurological examination and was subsequently confirmed by CT scanning. CSDH was considered to have recurred when neurological signs and/or symptoms augmented, reoccured, or did not improve within 1 month of the original primary procedure and the hematoma volume increased. Only
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patients who fulfilled both criteria underwent repeated operation. Residual hematoma into subdural cavity following the first operational procedure without accompanying signs and
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symptoms, and with no mass effect was not recognized as recurrence or as an indication for repeated surgery in this study. In cases of bilateral hematomas, the outcome of both
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hematomas were analysed separately.
Results
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The mean age of the patients was 79.2 years (range 46-97 years) and included 274 men and 140 women. Because 114 patients underwent bilateral operations, we analysed a total
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of 528 operation sites of CSDH. Symptoms and signs
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390 patients (94.2%) had a history of trauma, most of which were minor; transient loss of consciousness or posttraumatic amnesia was recognized in 24 patients (5.8%). The mean interval from head injury to operation was 9 weeks (range 4-15 weeks). The hematoma was located on the left side in 138 cases, on the right side in 162 cases, and bilaterally in 114 patients. The leading initial symptoms were headache (n= 204), hemiparesis (n=274), and deterioration of level of consciousness (n= 118). The demographic and baseline characteristics of the subject population are listed and compared in Table 1. 176 patients
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(42.5%) had coagulopathies: thrombocytopenia caused by leukemia was present in 6 patients, while 160 patients received antiaggregant (n=126) and anticoagulant (n=34) therapy; 10 cases were dialytic patients. A history of head injury was unclear in most patients who presented with associated coagulopathy. Outcome The mean duration of hospitalization was 8 days (range 4-32 days); patients were discharged home or transferred to other phisyotherapic services according to their neurological status. Patients with no complications were usually discharged on the seventh day postsurgery and followed up for at least 2 months as outpatient in our
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Department. Postoperative clinical outcomes between the 4 groups were compared. When hospital days and outcome at discharge (GCS) between the four groups were compared, no statistically significant differences were found. After surgery, follow up CT scans were performed: the mean hematoma thickness decreased from 25.3 mm (range 17-34 mm) to
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7.9 mm (range 4-15 mm). Clot volume of subdural hematoma was measured also using the formula AxBxC/2: the mean pre-operative hematoma volume decreased significantly
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from 96 cm3 (range 13,6 cm3 - 141,4 cm3) to 17 cm3 (range 62 mm3 - 47,8 cm3) during the post-operative period.
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Primary endpoint: symptomatic recurrence requiring surgery For the entire study population, recurrent CSDH on the ipsilateral side requiring repeated
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surgical treatment was detected in 50 patients ( 9.47% ). According to surgical approach, there was no significant difference in recurrence rates between patients having burrholes (3.41%) or craniotomy (6.06%) (p=0.401) when controlling for other variables.
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According to drainage location, recurrence occurred in 16 cases (3,03%) in subgaleal drainage patients, while in 34 cases (6.44%) in subdural drainage cases. There were 1.5%
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of recurrence in Group Ia, while 1.9% in Group Ib; in Group IIa 6.3% of all the cases underwent reoperation for recurrence of the hematoma, while only 1.1% of recurrences were treated in Group IIb. Multivariate analyses revealed that, when adjusting for variables affecting recurrence rate, the between group statistical differences did not reach the level of significance. Recurrence was found in 36 cases (12%) of unilateral hematomas, while in 14 cases (12.2%) in bilateral CSDHs. None of the demographic, clinical, or radiological features correlated with postoperative recurrence except the use of preoperative antiplatelet therapy.
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Of the patients taking antiaggregants , 108/126 received a transfusion of platelets preoperatively, while 18 cases discontinued their medication for the traditional 7 days. For patients taking warfarin, reversal treatment was vitamin K associated to transfusion of plasma (19 cases) or clotting factors (15 cases). Recurrence occurred in 21.4% of 126 patients on antiplatelets (102 aspirin/ 24 clopidogrel) therapy and in 11.7% of 34 cases on anticoagulant (warfarin) therapy, while recurrence rate in patients with no antiplatelet/antiaggregant therapy was 5.9% (p=0.017). Furthermore, 2 dialytic patients underwent new operation for CSDH recurrence. The interval from the first operation to the reoperation ranged from 1 to 7 weeks.
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Secondary Endpoints: Complications Excluding recurrences, reoperation for complications was performed in 4.2% of cases and it was primarily due to acute hemorrhages. The frequency of re-intervention appeared to be lower in the burrhole group, while was higher in the craniotomy with subdural drainage
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group (5,3%) and in the craniotomy with subgaleal drainage group (6%). The overall group differences, however, did not reach the level of statistical significance (p=0.184).
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Postoperative acute hematoma occurred in 3.3% of patients with preoperative unilateral
hematoma, while it occurred in 3.5% of bilateral hematomas: the difference was not statistically significant. Postoperative complications related to the surgical intervention
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are summarized in Table 2 and 3. Infection occurred in 2.9% of patients. 4 patients with superficial wound infection underwent superficial wound revision in addition to
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intravenous antibiotic therapy. In 6 cases, deep infection was surgically evacuated. Symptomatic postoperative pneumocephalus needing surgical revision was seen in 4 cases (0.76%): 2 cases in group IIa and the other two in Group IIb. New-onset seizures
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were seen in 12 patients with subdural drainage in the postoperative period. In 8 cases the subdural drainage was in contact with the cortical surface of the brain and was removed
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with immediate resolution of the symptoms, while 4 patients had partial motor seizures that were managed successfully by the application of anticonvulsant drugs. CT scans of the patients with new-onset seizures in Group IIb revealed acute subdural hematoma with specks of pneumocephalus. There were no significant statistical differences in seizures between the two drainage groups. 14 patients (2.65%) developed acute subdural rebleeding in
the
immediate postoperative period.
12
of them
were on
antiplatelets/anticoagulants in the preoperative period; higher incidence of postoperative hemorrhagic complications were observed in the patients on anticoagulant therapy
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(17.6%) compared to the group on antiplatelets therapy (4.8%) and no coagulopathy group (0.8%) (p=0.019). Of these patients, all underwent craniotomy under general anesthesia and evacuation of the present blood clots. Intracerebral hemorrhage was observed in 4 patients (2 in Group Ia and 2 in Group IIa). Perioperative mortality rates within 30 days after surgery was 1.52 % of total cases (2.5%of Group Ia and 1.8% of Group IIa). Causes of death included development of acute subdural hematoma after surgery in 4 cases, while the other 4 patients arrived to our emergency room unconscious and died with no improvement after surgery.
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Discussion In this population based study of patients with chronic subdural hematoma treated with four different treatment regimens, we didn’t find any difference in recurrence between groups. However, the use of preoperative antiplatelets therapy was associated to a higher
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incidence of recurrence, while preoperative anticoagulant therapy was a significant risk factor for postoperative acute subdural hemorrhage. Surgical Approach
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According to experience and preference of the surgeons and to the radiological appearance of the subdural hematoma, we performed 2 different surgical procedures: burr
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hole and „mini” craniotomy. Burr hole craniostomy is the most commonly procedure performed in the treatment of CSDH within the last 20 years. It is a simple and widely practised technique with a recurrence rate of 0-28% and an overall morbidity of 0,9%
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[1,3,5,14,24,39,51,54]. Recurrence of CSDH after the first burr hole craniostomy is not rare, with a reported incidence of 7-18% [13,23,34,36]. Craniotomy is reported to be the way of surgical treatment with the least risk of recurrence, but has a greater related
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morbidity and mortality: this because in the series of craniotomy are included patients probably with higher risk of recurrence or had worse preoperative status [12,43]. In our
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study, we performed craniotomy in 232 cases. Recurrence are statistically significant in multilocular collections:
analysing the factors that can predict recurrence of the
hematomas, the laminar separated type of CSDH have a statistically significant correlation with the recurrence of the hematomas [7]. In our series, the choice of the type of procedure was related to CT findings on admission; non-liquefied hematomas with multilayer loculations with a web- or net-like structure, multiple compartments, mostly septated, underwent craniotomy and membranectomy. In view of high recurrences for multilocular hematomas, in these subtypes burr hole craniostomy appeared to be not
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adequate to intercept and drain all the multiloculations of the hematoma, thus we performed a craniotomy [7]. Furthermore, we preferred craniotomy in cases of mixed density subdural collection because hyperdense material was easier to remove using this surgical approach. Drainage following surgical evacuation of the subdural hematoma results in better outcome [23,49]. Most surgical strategies include the use of a draining system with the catheter tip inserted into the subdural space. The use of a subdural drain associated to burr hole craniectomy increases drainage volume and lowers the risk of recurrence of the subdural hematoma [23]. A comprehensive evidence-based systematic review comparing several randomized controlled trials about surgical treatment for
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chronic subdural hematomas involving more than 1900 patients was performed by Ivamoto et al.: the recurrence rate between the drainage group (5% of recurrences) and the group without drainage (33% of recurrences) was statistically significant (P<0,01) [23] . In their prospective multicenter study, Glancz et al. specified that position of drain did not appear to influence recurrence rate of the subdural hematoma (subdural drain
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7.7% vs subgaleal drainage 9.1%)[19]. Sjavik et al. observed higher recurrence rate in the subdural drain group compared to subgaleal drainage cohort, implying an inadequate
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evacuation of the subdural hematoma in the former group[44]. In our cases, the choice of subdural vs subgaleal drain was selected intraoperatively; the subgaleal drainage was
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preferred in cases of rapid brain expansion after CSDH evacuation, while subdural drain was inserted in those cases of atrophic brain or large subdural areas. The subdural drainage was inserted in the frontal subdural space in most of the patients whose brain
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did not re-expand at the end of the drainage procedure. In our experience, the insertion of the drain under the galea is particularly trouble-free, because no manipulation of intracranial structures is necessary with limited risk of intracranial hemorrhage. In a
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prospective randomized study performed by Kaliaperumal et al., subgaleal drainage and subdural drainage were compared in 50 patients following burr hole: no significant
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differences were detected [26]. Gazzeri et al. published a large series on subgaleal drain through a „mini” craniotomy reporting 7.6% hematoma recurrence, a finding comparable to our current cohort of subgaleal drain associated to craniotomy (9.4%). In a retrospective single-center study, Zumofen et al. analyzed the results of all patients following double burr hole trepanation using a subperiostal passive closed-drainage system [55]. Hematoma persistence or recurrence occurred in 13.1% of the cases. In contrast to our cohort of subgaleal drainage, the choice of a double burr hole strategy allowed Zumofen et al. to abstain from active perioperative draining methods and to avoid
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enlargement of the burr holes [55]. In the literature, reintervention rates after burr hole surgery with subdural drains vary between 8.3% and 26.5% [2,8, 13,22,35]. Results from the series with subgaleal drainage reported by Gazzeri et al. [17] with a reoperation rate of 7.6%, represent comparatively low incidences of recurrence. In the study of Bellut et al. comparing subdural vs subgaleal drainage methods, there were no statistically significant differences regarding postoperative hematoma remnants, rates of recurrences, mortality, and complications, between the groups [4]. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage
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system. Our data strongly suggest that subgaleal drainage techniques are not inferior to the traditional subdural drainage methods. Recent studies reported that there were no differences in perioperative morbidity between general and local anesthesia; also in our series, general anesthesia was not associated with higher morbidity and recurrence rate.
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Recurrence
Although chronic subdural hematoma is a well known curable disease in the aging
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population, the rate of reoperation is reported to be high, between 2.7 and 33% [10,20,42,44,47]. Postoperative recurrence of CSDH is not rare and has always been a
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source of frustration for neurosurgeons [18,29,32]. Prevention of hematoma recurrence and reduction of postoperative hygroma formation results not only from efficient hematoma drainage, but also depends on postoperative management that actively
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promotes adequate brain re-expansion [15,16,37,48]. Therefore, we advocate a significant period of flat bed rest in combination with mild intravenous hyperhydration, although there is contradictory advice about the risks and benefits of postoperative early
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mobilization versus bed rest [6]. The recurrence rate and the bad outcome of CSDH are higher in patients with greater width of hematoma, cerebral atrophy, and significant
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subdural air accumulation. Our decision to proceed with revision surgery was based on clinical symptoms correlated with imaging. In our series, we found only 8 cases (5%) of recurrence in the burr hole with subdural drainage group, while there were 10 (12.5%) in Group Ib; looking at recurrences in the cranitomies group, in Group IIa 11.6% of cases underwent reoperation for recurrence, while 9.4% of hematoma recurrences were treated in Group IIb. Although Brennan et al. reported that the preoperative prescription of antiplatelet agents was not an independent independent factor for recurrence in their series, antiplatelet and anticoagulant medications have been implicated in the
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development ad recurrence of CSDH [6]. In the current study, the preoperative prescription of antiplatelets therapy was a statistically significant risk factor for recurrence. Acute subdural/epidural and intracerebral hemorrhage Postoperative acute intracerebral hemorrhage was reported in some series in association with the use of subdural drain and burr hole techniques [27]. Gazzeri et al.and Zumofen et al. have signified that the use of a subdural drain with burr hole may lead to intracerebral hemorrhage. These drainage catheters may penetrate into the brain parenchyma or injure bridging veins. In our current series, in all 4 cases of intracerebral
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hemorrhage a subdural drain was used. Reoperation secondary to acute hemorrhage was performed in 7 cases: in 6 of these, a subdural drainage was used. The use of anticoagulant agents was observed to be significantly associated with postoperative acute subdural
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hematoma (p=0.019) when controlling for other variables. Pneumocephalus
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Massive postoperative pneumocephalus is one of the main factors complicating the adhesion of the inner and outer membrane, thus it induces a postoperative reaccumulation
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of chronic subdural hematoma [36 ]. Symptomatic pneumocephalus has been reported to range from 0 to 10% in literature.
In our study, symptomatic postoperative
Epilepsy
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pneumocephalus was seen in 4 cases (0.8%): all the cases were in the craniotomy groups.
Postoperative seizure in CSDH is reported to occur in 7% to 13.7% of cases [9, 41 ]. In
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the study of Zumofen, in which subgaleal drainage was used, postoperative seizure was noted in 8.2% of patients [55]. This comparatively low incidence may corroborate the
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theory reported by Gazzeri et al. [17 ] stipulating that the absence of an irritating subdural drain in direct contact with the cortical surface of the brain and the hematoma capsule, moderates the risk of seizure during the phase of brain re-expansion. In this study we didn’t observe significant differences in seizures between patients having subdural or subgaleal drain (p=0.359). There were new-onset seizures in 14 patients (3.4%): 12 patients had a subdural drainage in contact with the cortical surface of the brain, which was immediately removed, while 2 patients had partial motor seizures that were managed successfully with anticonvulsant drugs.
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Infection One cited complication for subdural drain is empyema, occurring in 2,1% of postoperative patients [41]. Gazzeri et al. [17] reported a very low incidence of postoperative deep infection in relation with extra-cranial placement of drain. The absence of foreign material in direct contact with intracranial structures possibly limits the propagation of infection agents into deep compartments, potentially moderating the formation of secondary empyema. In our study we had a low incidence of patients with empyema (8 cases), with the infection localized in the sudural space: in six cases the patients had a subdural drainage, while only in two cases had a subgaleal drainage.
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Although infection rate was higher in patients with subdural drain, it was not statistically significant. Mortality
Mortality varies in recent series from 1,2 to 4,3%; coagulopathy, respiratory and cardiovascular complications in elderly patients and poor preoperative neurological status
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are contributory causes of postoperative death [34,40]. The only factor that has a statistically significant correlation with outcome is preoperative neurologic grade. In our
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current series the mortality rate was 1.52%. There are some limitations to our study. First, limitations inherent to retrospective assessment are present in this study, but the clinical
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relevance of recurrence and complications remain incontestable. Second, a major bias is that interventions were not chosen randomly, but each surgeon performed a different surgical approach deciding on a case to case basis. Another limitation is that no
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assessment for seizures by EEG was performed. Further, the question of postoperative drain duration was not assessed in our study. Conclusions
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Recurrence rate and functional outcome after surgical drainage of CSDH does not appear to be affected by surgical technique (craniotomy vs burrhole) and drainage location.
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Preoperative antiplatelet treatment was predictive of higher recurrence rate, while preoperative anticoagulant medication was an independent risk factor for acute postoperative hemorrhage. To our opinion, choice of surgical procedure and type of drainage has to be guided by surgeon preference and intraoperative findings. In cases of septated hematomas, with multilayer loculations, we preferred to perform a „mini” craniotomy. We selected subgaleal drain in cases of rapid brain expansion, while we inserted subdural drainage in cases of atrophic brain. These findings suggest that surgeons may elect procedures on a case-by-case basis, but variations in practice may not influence
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outcomes. Further prospective randomized studies are required to determine whether standardization of surgical management can improve patients outcome.
We would like to thank Simona Matarrese e Serena Bellisari for their invaluable support in data collection. Funding-No funding was received for this research.
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Conflict of Interest: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. “For this type of study formal consent is not required.”
Conflict of interest and disclosures: none.
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There is not any kind of commercial interest in connection with the submitted article
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51. Weisse A, Berney J Chronic subdural haematomas. Results of a closed drainage method in adults. Acta Neurochir (1994) 127:37–40. 52. White M, Mathieson CS, Campbell E, Lindsay KW, Murray L Treatment of chronic subdural haematomas – a retrospective comparison of minicraniectomy versus burrhole drainage. Br J Neurosurg (2010) 24: 257-260
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53. Yasuda CL, Morita ME, Nishimori FY, Yasuda AM, Alves HL Chronic subdural hematoma: study of 161 patients and the relationship with coagulation abnormalities. Arq Neuropsiquiatr (2003)61: 1011-1014
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54. Yoshimoto Y, Kwak S Frontal small craniostomy and irrigation for treatment of chronic subdural haematoma. (1997) Br J Neurosurg;11:150–1
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55. Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery(2009) 64:1116-22
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Group IIA 204 (54,2%) 224 (42,4%)
Group IIB 52 (12,5%) 66 (12,5%)
274 / 140
64/44
37/13
141/63
32/20
0.128
76,3
74,9
76,3
76,4
77,2
0.188
Side of the haematoma (%) Right Left Bilateral
162 (39%) 138 (33,5%) 114 (27,5%)
48 (44,4%) 10 (9,3%) 50 (46,3%)
10(20%) 12(22%) 30(58%)
91(44,2%) 93(46%) 20(9,8%)
13(25%) 25(48%) 14(27%)
0.342 0.282 0.696
Location ( %) Frontal Fronto-parietal Parietal Fronto-parietooccipital
38(7,2%) 358(67,8%) 28(5,3%) 104(19,7%)
9(5,7%) 97(61,4%) 11(7%) 41(25,9%)
5(6,3%) 46(57,5%) 0(0%) 29(36,2%)
19(8,5%) 179(79,9%) 7(3,1%) 19(8,5%)
5(7,6%) 36(54,5%) 10(15,2%) 15(22,7%)
0.166 0.205 0.475 0.386
22(9,8%) 16(7,8%) 114(55,8%) 17(8,3%) 56(27,4%) 24(11,7%)
3(5,7%) 5(9,6%) 32(61,5%) 4(7,7%) 24(46,1%) 4(7,7%)
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14(12,9%) 13(12%) 58(53,7%) 16(14,8%) 44(40,7%) 21(19,4%)
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44 (10,6%) 39 (9,4%) 230 (55,5%) 41(9,9%) 144(34,7%) 58 (14%)
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Comorbidities (%) Dementia Ischemic Heart disease Arterial hypertension Arrhythmia Diabetes-mellitus Cerebrovascular Disease
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Mean Age yrs
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Gender M/F
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Total patients Total of Surgical Procedures (%)
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Group IB 50 (12,1%) 80 (15,2%)
P-value
414 528
Group IA 108 (26,2%) 158 (29,9%)
5 (10%) 5 (10%) 26 (52%) 4(8%) 20(40%) 7(14%)
0.465 0.401 0.576 0.335 0.166 0.286
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Coagulopathies (%) Antiplatelet Medications Warfarin Others
32(29,6%) 9(8,3%) 4(3,7%)
16(32%) 4(8%) 1(2%)
66(32,3%) 17(15,6%) 83,9%)
12(23%) 4(7,6%) 3(5,7%)
0.342 0.181 0.057
290 (70%) 124 (30%)
46(42,5%) 62(57,5%)
19(38%) 33(62%)
179(87,7%) 23(12,3%)
46(88,4%) 6(11,6%)
0.485 0.628
Mean preoperative GCS Score
13,7
13,7
13,9
13,7
13,8
0.282
Mean GCS Score at F.U.
14,2
14
14,6
14,2
14,5
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Anestesia (%) General Local
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126(30,4%) 34(8,2%) 16(3,8%)
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Table 1. Demographic data and baseline characteristics of the subject population
0.418
Group IA
Group IB
Group IIA
Group IIB
Total
Approaches Recurrence
158 8(5.06%)
80 10 (12.5%)
224 26 (11.6%)
66 6 (9.1%)
Reoperation for complications Deep Infection Acute Hemorrhage (Epi- or Subdural) Brain Hemorrhage Tension Pneumocephal us Epileptic crisis
4(2.5%)
2(2.5%)
12 (5.3%)
4 (6%)
528 50 (9.47%) 22(4.2%)
2 (1.27%) 2 (1.27%)
2 (2.5%) 0
4 (1.8%) 10 (4.46%)
0 2 (3.03%)
8(1.52%) 14 (2.65%)
2 (1.27%)
0
2 (0.89%)
0
0
0
2 (0.89%)
2 (3.03%)
6 (3.8%)
0
6 (2.68%)
2 (3.03%)
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P value between all groups’
P value between groups I (A+B) and II (A+B)
0.420
0.401
0.184
0.101
0.836 0.373
1.000 0.133
Death
4 (2.53%)
0
4 (1.8%)
0
0.836
1.000
4 (0.76%)
0.361
0.503
14(2.65% ) 8 (1.52%)
0.680
1.000
0.631
1.000
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4(0.76%)
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Table 2. Complications in 414 cases, for a total of 528 approaches (114 hematomas were bilateral)
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Group IA: Burr hole and subdural drainage; Group IB: Burr hole and subgaleal drainage; Group IIA: Craniotomy and subdural drainage; Group IIB: Craniotomy and subgaleal drainage. (Pearson’s chi-square test, 2-sided test)
Craniotomy
P value between groups I (A+B) Burrhole and II (A+B) Craniotomy
Subdural drain
Subgaleal drain
238 18 (7.5%) 6 (2.5%)
290 32 (11%) 16 (5.5%)
0.870 0.401 0.101
382 34 (8.9%) 16 (4.1%)
146 16 (10.9%) 6 (4.1%)
P value between all groups IA –IIA (subdural drain) And IB-IIB (subgaleal drain) 0.266 0.647 1.000
4 (1.6%) 2 (0.8%)
4 (1.3%) 12 (4.1%)
1.000 0.133
6 (1.6%) 12 (3.2%)
2 (1.4%) 2 (1.4%)
1.000 0.433
2 (0.8%)
2 (0.6%)
1.000
4 (1%)
0
0
4 (1.3%)
0.503
2 (0.5%)
2 (1.4%)
6 (2.5%) 4 (1.6%)
8 (2.7%) 4 (1.3%)
1.000 1.000
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Approaches Recurrence Reoperation for complications Deep Infection Acute Hemorrhage (Epi- or Subdural) Brain Hemorrhage Tension Pneumocephal us Epileptic crisis Death
Burrhole
-p
19
12 (3.2%) 8 (2.1%)
2 (1.4%) 0
0.653
0.359 0.546
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Table 3. Complications in 414 cases, comparing treatment characteristics: burrholes vs craniotomies and subdural vs subgaleal drainages