Skip to main content
SpringerLink
Log in

Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

The objective of this paper was to evaluate whether available evidence supporting placement of subdural drain placement after evacuation of chronic subdural haematoma (CSDH) is applicable to a cohort of patients managed by us. In this observational cohort study, clinical follow-up was obtained in 166 patients who underwent burr hole evacuation of CSDH without placement of subdural drain followed by 3 days of bed rest. The primary outcome studied was recurrence requiring reoperation. Factors predicting recurrence were also analysed. We compared the patient characteristics and management protocols in our cohort with that in reports supporting drain placement to determine whether such evidence is relevant to our patient group. The mean age of our patients was 58 ± 17 years (range, 1 to 89 years). Sixteen of the 166 (9.6%) patients presented with symptomatic recurrence. The median time to reoperation for recurrence (15 of 16 patients) after the primary procedure was 17 days (range, 2 to 68 days). Antiplatelet and anticoagulant therapy was the only factor that was significantly associated with recurrence (p = 0.01). There were no infective or non-infective complications in our patient cohort. Our patient cohort and outcomes differed from those reporting drain placements in the following parameters: they were a decade younger, all patients received bed rest for 3 days after surgery and the recurrence rate was similar to that reported in the drained groups but significantly less than that reported in the non-drained groups. Routine placement of drain following burr hole evacuation of CSDH should only be done after careful comparison of the patient cohort under consideration and those reporting superior outcomes with drains. Evidence-based medicine supports such an approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Alcala-Cerra G, Young AM, Moscote-Salazar LR, Paternina-Caicedo A (2014) Efficacy and safety of subdural drains after burr-hole evacuation of chronic subdural hematomas: systematic review and meta-analysis of randomized control trials. World Neurosurg 82:1148–1157

    Article  PubMed  Google Scholar 

  2. Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, Arjmand P, Baronia B, Reddy K, Murty N, Singh S (2014) Chronic subdural hematoma management: a systematic review and meta-analysis of 34829 patients. Ann Surg 259:449–457

    Article  PubMed  Google Scholar 

  3. Behari S (2014) Closed drainage following surgery for chronic subdural hematoma: complacency causes critical lapses. Neurol India 62:121–123

    Article  PubMed  Google Scholar 

  4. Javadi A, Amirjamshidi A, Aran S, Hosseini SH (2011) A randomized controlled trial comparing the outcome of burr-hole irrigation with and without drainage in the treatment of chronic subdural hematoma. A preliminary report. World Neurosurg 75:731–736

    Article  PubMed  Google Scholar 

  5. Kaliaperumal C, Khalil A, Fenton E, Okafo U, Kaar G, O’Sullivan M, Marks C (2012) A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural hematoma. Acta Neurochir 154:2083–2088

    Article  PubMed  Google Scholar 

  6. Kutty SA, Johny M (2014) Chronic subdural hematoma: a comparison of recurrence rates following burr-hole craniostomy with and without drains. Turk Neurosurg 24:494–497

    PubMed  Google Scholar 

  7. Laumer R, Schramm J, Leykauf K (1989) Implantation of a reservoir for recurrent subdural hematoma drainage. Neurosurgery 25:991–996

    Article  CAS  PubMed  Google Scholar 

  8. Lind CRP, Lind CJ, Mee EW (2003) Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains. J Neurosurg 99:44–46

    Article  PubMed  Google Scholar 

  9. Okano A, Oya S, Fujisawa N, Tsuchiya T, Indo M, Nakamura T et al (2014) Analysis of risk factors for chronic subdural hematoma recurrence after burr hole surgery: optimal management of patients on antiplatelet therapy. Br J Neurosurg 28:204–208

    Article  PubMed  Google Scholar 

  10. Qian Z, Yang D, Sun F, Sun Z (2016) Risk factors for recurrence of chronic subdural hematoma after burr hole surgery: potential protective role of dexamethasone. Br J Neurosurg. doi:10.1080/02688697.2016.1260686

    PubMed  Google Scholar 

  11. Robinson RG (1984) Chronic subdural hematoma: surgical management in 133 patients. J Neurosurg 61:263–268

    Article  CAS  PubMed  Google Scholar 

  12. Wakai S, Hashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M (1990) Efficacy of closed system drainage in treating chronic subdural hematoma: a prospective comparative study. Neurosurgery 26:771–773

    Article  CAS  PubMed  Google Scholar 

  13. Weigel R, Schmiedek P, Krauss JK (2003) Outcome of contemporary surgery for chronic subdural hematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:937–943

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Weigel R, Schlickum L, Weisser G, Krauss JK (2015) Treatment concept of chronic subdural hematoma according to an algorithm using evidence-based medicine-derived key factors: a prospective controlled study. Br J Neurosurg 29:538–543

    Article  PubMed  Google Scholar 

  15. Adeolu AA, Rabiu TB, Adeleye AO (2012) Post-operative day two versus day seven mobilization after burr-hole drainage of subacute and chronic subdural hematoma in Nigerians. Br J Neurosurg 26:743–746

    Article  PubMed  Google Scholar 

  16. Erol FS, Topsakal C, Faik Ozveren M, Kaplan M, Tiftikci MT (2005) Irrigation vs. closed drainage in the treatment of chronic subdural hematoma. J Clin Neurosci 12:161–163

    Article  Google Scholar 

  17. Jack A, O’Kelly C, McDougall C, Max Findlay J (2015) Predicting recurrence after chronic subdural hematoma drainage. Can J Neurol Sci 42:34–39

    Article  PubMed  Google Scholar 

  18. Kurabe S, Ozawa T, Watanabe T, Aiba T (2010) Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients. Acta Neurochir 152:1171–1174

    Article  PubMed  Google Scholar 

  19. Leroy HA, Aboukais R, Reyns N, Bourgeious P, Labreuche J, Duhamel A et al (2015) Predictors of functional outcomes and recurrence of chronic subdural hematomas. J Clin Neurosci 22:1895–1900

    Article  PubMed  Google Scholar 

  20. Liu W, Bakker NA, Groen RJ (2014) Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121:665–673

    Article  PubMed  Google Scholar 

  21. Nakaguchi H, Tanishima T, Yoshimasu N (2001) Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence. J Neurosurg 95:256–262

    Article  CAS  PubMed  Google Scholar 

  22. Nakajima H, Yasui T, Nishikawa M, Kishi J, Kan M (2002) The role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial. Surg Neurol 58:385–387

    Article  PubMed  Google Scholar 

  23. Safain M, Roguski M, Antoniou A, Schirmer CM, Malek AM, Riesenburger R (2013) A single center's experience with the bedside subdural evacuating port system: a useful alternative to traditional methods for chronic subdural hematoma evacuation. J Neurosurg 118:694–700

    Article  PubMed  Google Scholar 

  24. Sambasivan M (1997) An overview of chronic subdural hematoma: an experience with 2300 cases. Surg Neurol 47:418–422

    Article  CAS  PubMed  Google Scholar 

  25. Schwarz F, Loos F, Dunisch P, Sakr Y, Safatli DA, Kalff R, Ewald C (2015) Risk factors for reoperation after initial burr hole trephination in chronic subdural hematomas. Clin Neurol Neurosurg 138:66–71

    Article  PubMed  Google Scholar 

  26. Singh AK, Suryanarayanan B, Choudhary A, Prasad A, Singh S, Gupta LN (2014) A prospective randomized study of use of drain versus no drain after burr-hole evacuation of chronic subdural hematoma. Neurol Ind 62:169–174

    Article  Google Scholar 

  27. Tabaddor K, Shulmon K (1977) Definitive treatment of chronic subdural hematoma by twist-drill craniostomy and closed-system drainage. J Neurosurg 46:220–226

    Article  CAS  PubMed  Google Scholar 

  28. Ohaegbulam SC (1981) Surgically treated traumatic subacute and chronic subdural haematomas: a review of 132 cases. Injury 13:23–26

  29. Probst C (1988) Peritoneal drainage of chronic subdural hematomas in older patients. J Neurosurg 68:908–911

  30. Unterhofer C, Freyschlag CF, Thome C, Ortler M (2016) Opening the internal hematoma membrane does not alter the recurrence rage of chronic subdural hematomas: a prospective randomized trial. World Neurosurg 92:31–36

  31. Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, Richards HK, Marcus H, Parker RA, Price SJ, Kirollos RW, Pickard JD, Hutchinson PJ (2009) Use of drains versus no drains after burr-hole evacuation of chronic subdural hematoma: a randomised controlled trial. Lancet 374:1067–1073

    Article  PubMed  Google Scholar 

  32. Berghauser Pont LM, Dirven CM, Dippel DE, Verweij BH, Dammers R (2012) The role of corticosteroids in the management of chronic subdural hematoma: a systematic review. Eur J Neurol 19:1397–1403

    Article  CAS  PubMed  Google Scholar 

  33. Tyson G, Strachan WE, Newman P, Winn RH, Butler AB, Jane JA (1980) The role of craniectomy in the treatmen of chronic subdural hematomas. J Neurosurg 52:776–781

    Article  CAS  PubMed  Google Scholar 

  34. Abouzari M, Rashidi A, Rezaii J, Esfandiari K, Asadollabi M, Aleali H, Abdollahzadeh M (2007) The role of postoperative patient posture in the recurrence of traumatic chronic subdural hematoma after burr-hole surgery. Neurosurgery 61:794–797

    Article  PubMed  Google Scholar 

  35. Bakheet MF, Pearce LA, Hart RG (2015) Effect of addition of clopidogrel to aspirin on subdural hematoma: meta-analysis of randomized clinical trials. Int J Stroke 10:501–505

    Article  PubMed  Google Scholar 

  36. Wada M, Yamakami I, Niguchi Y, Tanaka M, Suda S, Ono J, Saeki N (2014) Influence of antiplatelet therapy on postoperative recurrence of chronic subdural hematoma: a multicenter retrospective study in 719 patients. Clin Neurol Neurosurg 120:49–54

    Article  PubMed  Google Scholar 

  37. Cohen AM, Stavri PZ, Hersh WR (2004) A categorization and analysis of the criticisms of evidence-based medicine. Int J Med Inf 73:35–43

    Article  Google Scholar 

  38. Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y, Kirino T (1997) The relationship of preoperative magnetic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma. J Neurosurg 87:870–875

    Article  CAS  PubMed  Google Scholar 

  39. Guyatt GH, Haynes RB, Cook DJ, Green L, Naylor CD, Wilson MC, Richardson WS (2000) Users’ guides to the medical literature XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. JAMA 284:1290–1296

    Article  CAS  PubMed  Google Scholar 

  40. Cohen AM (2004) Criticisms of evidence-based medicine. Evid Based Cardiovasc Med 8:197–198

    Article  PubMed  Google Scholar 

  41. Goldman JJ, Shih TL (2011) The limitation of evidence-based medicine- applying population-based recommendations to individual patients. Virtual Mentor 13:26–30

    Article  PubMed  Google Scholar 

  42. Greenhalgh T, Howick J, Maskrey N, Evidence based Medical Renaissance Group (2014) Evidence based medicine: a movement in crisis? BMJ 348:g3725

    Article  PubMed  PubMed Central  Google Scholar 

  43. Sackett DL, Rosenberg WC, Gray JAM, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312:71–72

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Timmermans S, Mauck A (2005) The promises and pitfalls of evidence-based medicine. Health Aff 24:18–28

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurological Sciences, Christian Medical College, Vellore, Tamilnadu, 632004, India

    Laxminadh Sivaraju, Ranjith K Moorthy & Vedantam Rajshekhar

  2. Department of Biostatistics, Christian Medical College, Vellore, Tamilnadu, India

    Visalakshi Jeyaseelan

Authors
  1. Laxminadh Sivaraju
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ranjith K Moorthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Visalakshi Jeyaseelan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vedantam Rajshekhar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ranjith K Moorthy.

Ethics declarations

Funding

No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

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 and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study, formal consent is not required as it was a mostly retrospective audit of the outcomes following surgery in a cohort of patients with CSDH.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sivaraju, L., Moorthy, R.K., Jeyaseelan, V. et al. Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach. Neurosurg Rev 41, 165–171 (2018). https://doi.org/10.1007/s10143-017-0831-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-017-0831-2

Keywords

Search

Navigation