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) BURR HOLE GROUP Complete clinical recovery 85. 7%(36) No change in clinical condtion or worsening 31. 1%(47) No change in clinical condtion or worsening 14. 3%(06)
§ 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.
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