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Dreno Subdural X Subperiosteal
Dreno Subdural X Subperiosteal
C
4031 Basel, Switzerland.
hronic subdural hematoma (cSDH) establishing and implementing effective patient
Email: jehuda.soleman@gmail.com is one of the most common neuro- management is essential.
surgical entities which effects mostly Surgical evacuation of the hematoma via
Received, September 5, 2018. elderly people and is associated with substantial burr-hole drainage is generally the treatment of
Accepted, February 26, 2019.
morbidity and mortality1-3 ; a trend towards choice for patients with symptomatic cSDH.2,5,6
Copyright
C 2019 by the
higher incidence rates is expected.4 Therefore, Recurrence rate after burr-hole drainage of
Congress of Neurological Surgeons cSDH is estimated at approximately 10%; cSDH
recurrence causes considerable morbidity, and
ABBREVIATIONS: CRF, case report form; cSDH, is therefore a major focus of research.3,4,7 A
chronic subdural hematoma; CT, chronic subdural
hematoma; GCS, Glasgow Coma Scale; GOS,
randomized controlled trial by Santarius and
Glasgow Outcome Scale; mRS, modified Rankin colleagues8 demonstrated that the insertion of a
Scale; MLS, midline shift; SDD, subdural drain; SPD, subdural drain (SDD) left in situ after burr-hole
Subperiosteal drain evacuation significantly reduces cSDH recur-
rence requiring redrainage (9.3% vs 24.0%
Supplemental digital content is available for this article at
www.neurosurgery-online.com. recurrence with vs without drain), and improves
functional outcomes. These SDDs are positioned
between the dura and the cortex (underneath the calvarium), in about 7 to 8 cm apart from each other over the maximum width of
proximity to the cortical surface, bridging veins, and hematoma the hematoma. The dura mater was opened with a cruciate incision and
membranes, which may lead to iatrogenic injury of these struc- coagulated. The subdural hematoma was then washed out with warm
continuity-corrected modification of Wilson’s score method.20 Outcome sponding author had full access to all data in the study and had final
scores were analyzed using a 2-sided t-test and are presented as responsibility for the decision to submit for publication.
means and standard deviation. In case of violation of the normalized
assumption, median and interquartile range were calculated, while
proportions were compared using the Mann–Whitney U-test. RESULTS
Categorical data are presented as frequencies and proportions and
compared using the chi-square or fisher’s exact test (in case of cell count A total of 220 patients were recruited between April 15,
under 5). 2013, and December 9, 2015. The last follow-up examination
All statistical analyses were done using R (Comprehensive R Archive took place on December 6, 2016. A total fo 170 patients
Network [CRAN], R Foundation for Statistical Computing, Vienna, were randomly assigned to receive SDD, 113 to receive SPD;
Austria, Version 3.2.2). The trial was overseen by an independent data all patients contributed data for the primary outcome analysis
monitoring committee. (Figure 2). Due to crossover of 14 patients from the SDD to
the SPD group and seven patients from the SPD to the SDD
group, the per protocol analysis consisted of 120 patients in the
Funding Source SPD group and 100 patients in the SDD group. Demographic,
The funder of the study had no role in study design, data collection, clinical, and radiological baseline characteristics are presented in
data analysis, data interpretation, or writing of the report. The corre- Table 1.
drain insertion point and the subdural space, thus elevating the
TABLE 2. Clinical Outcomes of the Per Protocol Population risk of deep infections. The reason for the higher rate of super-
ficial infections in the SDD group might be due to the fact,
SDD SPD
Variable (n = 110) (n = 120) P-value
that the insertion of an SDD is sometimes difficult leading to
more manipulation of the drain itself, also at the level of the
Length of stay in days 6.0 (5·0-8·0) 6.0 (5.0-9.2) .918 skin, which might influence superficial infection rates. Iatrogenic
GCS 14–15 brain injury can be devastating, leading to large bleedings in
24 h 91 (91%) 104 (82%) .576 the brain parenchyma, causing neurological deficits, seizures, and
Discharge 92 (93%) 108 (91%) .646 even death (Figure 4). Drain insertion techniques and types of
6 wk 87 (98%) 110 (97%) .40
12 mo 78 (99%) 93 (98%) 1
drains used vary from institution to institution. In our insti-
GOS 4–5 tutes, we place the SDD to the full length between the parietal
24 h 84 (84%) 96 (80%) .555 and the frontal burr hole within the subdural space, in order
Discharge 84 (84%) 102 (86%) .889 to achieve better drainage from within the subdural hematoma
6 wk 78 (87%) 97 (86%) 1 cavity (Figure 1). Others might only place the tip of the drain into
12 mo 65 (83%) 82 (86%) .74 the parietal burr hole to minimize the risk of brain injury. The
mRS 0–3
type of drain inserted into the subdural space might also affect
24 h 86 (86%) 97 (81%) .401
Discharge 88 (89%) 107 (91%) .834
brain injury, since a ventriculostomy tube, which is considered
6 wk 83 (93%) 100 (89%) .465 less traumatic and is slimmer in size than the Jackson-Pratt drain,
12 mo 73 (92%) 87 (92%) 1 might cause less iatrogenic brain damage. This might be the case;
Markwalder score 0–1 however, in our cohort one of the misplaced drains was a ventricu-
24 h 70 (70%) 82 (68%) .905 lostomy drain, showing that drain misplacement is probably
Discharge 72 (73%) 92 (78%) .462 independent of the drain type used. Interestingly, although SDD
6 wk 79 (88%) 100 (88%) 1
patients suffered more surgical infections and iatrogenic brain
12 mo 66 (83%) 87 (92%) .166
Improvement of injuries, it did not seem to affect outcome measurements (mRS,
neurological exam GOS, Markwalder score) or mortality. This might be due to the
24 h 87 (87%) 94 (85%) .696 fact that eight of the 12 surgical infections were superficial wound
Discharge 88 (88%) 109 (93%) .282 infections not influencing outcome or mortality, and only 3 of the
6 wk 69 (77%) 95 (86%) .205 5 iatrogenic bleeds caused by SDD led to neurological symptoms
12 mo 61 (78%) 68 (72%) .479 that influence the outcomes. Nevertheless, our data show a signif-
Data are number (%) and median (IQR). SDD: subdural drain, SPD: subperiosteal drain; icant benefit for the insertion of SPD for the prevention of
GCS: Glasgow coma scale; GOS: Glasgow outcome scale; mRS: modified ranking scale. surgical infections and iatrogenic brain injuries, while the fact
that this did not influence the outcomes might be random.
TABLE 3. Morbidity and Mortality of the Per Protocol Population TABLE 4. Radiological Outcome of the Per Protocol Population
to the treatment arm, and the treating surgeons were masked to comparable to SDD, while surgical infection rates and the occur-
outcomes. Lastly, our estimated recurrence rate of 7.0% was lower rence of iatrogenic brain injuries are significantly reduced. These
than the actual overall recurrence rate of 10%. This might have findings suggest that SPD can be used in routine clinical practice.
influenced the statistical power of our sample size and results.
Features such as being the largest trial to date analyzing recur- Disclosures
rence rates after insertion of SPD as compared to SDD, being Funded by the Research Foundation Kantonsspital Aarau. The funder of the
a prospective, randomized, multicenter study involving a rather study had no role in study design, data collection, data analysis, data interpre-
big number of patients and neurosurgeons, a low rate of patients tation, or writing of the report. The corresponding author had full access to all
data in the study and had final responsibility for the decision to submit for publi-
lost to follow up (1.36%), and a long follow up of 12 mo are cation. The authors have no personal, financial, or institutional interest in any of
important strengths of our trial. the drugs, materials, or devices described in this article.
CONCLUSION
REFERENCES
We conclude that the insertion of SPD after burr-hole drainage 1. Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H. The
of cSDH is an efficient and safe alternative to the insertion of course of chronic subdural hematomas after burr-hole craniostomy and closed-
an SDD. Recurrence rates of cSDH after inserting an SPD are system drainage. J Neurosurg. 1981;55(3):390-396.
2. Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for and following up on them, thereby contributing to the completeness of the data;
chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry. Marianne Schulz from the research office of the University Hospital in Basel,
2003;74(7):937-943. Switzerland and Anna Scrowther, Carline Perren, Sonja Schwenne, and Sylvie
comparison to the sub dural group. These factors did not seem to affect and possible seizures due to placement of drain. It is reassuring that
the outcome in this study and this topic can be relevant for the future anticonvulsants were not prophylactically used and the seizure rates were
studies. The other major point this is not clarified in detail is regarding comparable in the subgroups. It is worthy of note that adhering to strict