Chronic subdural hematoma-craniotomy vs burr hole trepanation introduction

CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION

INTRODUCTION

• 1)chronic subdural haematoma(CSDH) is common intracranial pathology in elderly people.

• 2)recurrence rate ranges 9.2-26.5% after surgical interventions.

• 3)incidence of CSDH likely to rise due to increase life expectancy &more number of people receiving anticoagulant ,antiplatelet agents.

• Craniocerebral injuries from acute subdural haematoma &subdural hygroma results in formation of chronic subdural haematoma.

MECHANISM:

• Neomembrane produced by dural border cells in unresolved hygroma results in vascularization with fragile blood vessels and repeated bleedings.

• Failure of resorption of coagulated blood with subsequent granulation tissue and angiogenesis with fragile blood vessels in setting of ASDH.

TREAT MENT OPTIONS

• 1)Burr hole craniotomy

• 2)trepanation &twist drill craniotomy with or without irrigation/with or without drainage.

• Ususal presentation of chronic subdural haematoma:

• 1)Headache

• 2)Decrease conciousness

• 3)Aphasia

• 4)Behavioral disturbances

• 5)Paresis

• 6)Seizure

• During 5 yrs study at neurosurgery department at Hannover (between march 2003-july 2008):

• Pre and post operative CT images taken.

• Pre-operative clinical appearance &post –operative clinical outcome.

RISK FACTORS:

• Anticoagulant therapy

• Antiplatelet agents

• Coagulopathy

• Alcohol abuse

• Out of 193 patients:

• 151 patients had osteoplastic craniotomy with subdural drainage and low suction vacuum reservior.

• 42 patients had burr hole trepanation with subdural drainage and low suction vacuum reservior.

• Careful irrigation with ringer lactate followed in every operation untill the irrigation solution remained clear.

• All the drains were removed within 3 days.

• Patient’s mean age 72.5 yrs

• Males:113(59%)

• Females:80(41%)

• Chronic subdural hematoma location:

• 90 cases(47%) in left hemisphere.

• 74 cases(38%)in right hemisphere.

• 29 cases(15%)in both hemisphere.

• 40%patients were receiving antiplatelet and anticoagulant therapy.

• Coagulopathy obsereved in 2% patients.

• Alcohol abuse present in 6% of patients.

• Most frequent clinical signs were:

• Hemiparesis:112(58%)

• Decrease conciousness:70(36.3%)

• Aphasia:46(23.8%)

• All the patients with above clinical signs showed chronic subdural hematoma in CThead.

Post-operative clinical improvement

• CRANIOTOMY GROUP

• Complete clinical recovery 68.9%(104)

• No change in clinical condtion or worsening 31.1%(47)

• Recurrence rate was 27.8%(42 cases) in patients treated with craniotomy &drainage

• And 14.3%(06 cases) in patients treated with burr hole drainage.

• Seizures were observed in 15 patients (6.7%) pre-operatively &in 14 patients (7.3%) post-operatively.

• 137 patients(70%)or their relatives documented history of head trauma.

• Mean interval for development of CSDH is 37.3 days(range 1-230 days.)

RECOVERY AND DISCHARGE INDICES

• 79 cases(52.3%)with craniotomy and sub dural drainage &

• 27 cases(64.3%)with burr hole and sub dural drainage were discharged home for self care.

• 16 cases(8.6%)discharged to another specialist department for treatment of accompyning disease.

• 8 cases(5.3%) in craniotomy group and

• 3 cases(7.2%) in burr hole group were sent to nursing home.

• 7 cases(4.6%)of craniotomy group and

• 1 case(2.4%) of burr hole group died in hospital stay because of internal disease not directly attributable to CSDH.

• Incidence of pre-op seizures was 6.7%

• Post-op seizures incidence:7.3%

• Chen-et-al correlated increase incidence of post-op seizures in patient with left unilateral CSDH and CT appearance of mixed density type lesion.

• Santarious-et-al randomised 215 patients with CSDH with drain and without drain.

• Use of drain with burr hole irrigation is associated with lower recurrence rate,,better neurological status at discharge and lower mortality at 6 months.

• Zakaria-et-al compared 42 patients treated with burr hole craniotomy(with drainage) without irrigation and 40 patientswith irrigation and drainage.

• No significant difference in outcome between both groups was observed.

• A recurrence rate was same (12.2%)

• Okado-et-al compared 20 patients treated by burr hole irrigation with 20 patients treated by burr hole drianage.

• Hospitalization (post-op)stay was 14.1 in drainage group.

• Hospitalization (post-op) stay was 25.5 in irrigation group.

CONCLUSION

• Single institution 5 yrs retrospective study of 193 patients was done with consideration of clinical presentation,surgical technique and outcome of CSDH.

• History of trauma recognised in 71% with mean interval of time gap of 37 days.

• Antiplatelet and anticoagulant therapy was present in 40% of patients.

• Most frequent pre-operative symptom was hemiparesis(58%)

• 75% of patient had surgery succesfully performed.

• 25% received revision surgery with 3 cases(1.6%)undergoing craniectomy as second revision.

• CSDH is a common disease very frequent in elderly population predominantly affecting male patients.

• Burr hole trepanation evacuation seems to lead to superior results.

• Osteoclastic craniectomy might represent surgical option in complicated recurrent cases.