CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION

1
CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR
HOLE TREPANATION
2
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.

3
(No Transcript)
4

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

5
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.

6
TREAT MENT OPTIONS

• 1)Burr hole craniotomy
• 2)trepanation twist drill craniotomy with or
  without irrigation/with or without drainage.

7

• Ususal presentation of chronic subdural
  haematoma
• 1)Headache
• 2)Decrease conciousness
• 3)Aphasia
• 4)Behavioral disturbances
• 5)Paresis
• 6)Seizure

8

• 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.

9
RISK FACTORS

• Anticoagulant therapy
• Antiplatelet agents
• Coagulopathy
• Alcohol abuse

10

• 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.

11

• Careful irrigation with ringer lactate followed
  in every operation untill the irrigation solution
  remained clear.
• All the drains were removed within 3 days.

12
(No Transcript)
13

• Patients mean age 72.5 yrs
• Males113(59)
• Females80(41)
• Chronic subdural hematoma location
• 90 cases(47) in left hemisphere.
• 74 cases(38)in right hemisphere.
• 29 cases(15)in both hemisphere.

14

• 40patients were receiving antiplatelet and
  anticoagulant therapy.
• Coagulopathy obsereved in 2 patients.
• Alcohol abuse present in 6 of patients.

15

• Most frequent clinical signs were
• Hemiparesis112(58)
• Decrease conciousness70(36.3)
• Aphasia46(23.8)
• All the patients with above clinical signs showed
  chronic subdural hematoma in CThead.

16
Post-operative clinical improvement

• CRANIOTOMY GROUP
• Complete clinical recovery 68.9(104)
• No change in clinical condtion or worsening
  31.1(47)

• BURR HOLE GROUP
• Complete clinical recovery85.7(36)
• No change in clinical condtion or worsening
  14.3(06)

17

• 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.

18

• 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.)

19
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.

20

• 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.

21
(No Transcript)
22

• Incidence of pre-op seizures was 6.7
• Post-op seizures incidence7.3
• Chen-et-al correlated increase incidence of
  post-op seizures in patient with left unilateral
  CSDH and CT appearance of mixed density type
  lesion.

23
(No Transcript)
24

• 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.

25

• 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)

26

• 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.

27
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.

28

• 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.

29

• 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.

30

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