Chronic subdural hematoma treatment in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits.
Chronic subdural hematoma are ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care.
Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier anticoagulation resumption treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates 1).
The traditional methods for managing symptomatic chronic subdural hematoma include evacuation via a burr hole with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation or craniotomy, with subdural drain or without drain placement.
Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic 2).
The less invasive surgical technique of bedside percutaneous subdural tapping and spontaneous haematoma efflux after twist drill craniostomy under local anaesthesia was prospectively analysed in 118 adult patients, 99 with unilateral and 19 with bilateral CSDH.
It can be recommended in all patients as a first and minimally invasive therapy, especially in patients in a poor general condition. Patients with septation visible on preoperative CT should be excluded from this form of treatment 3).
Twist-drill craniotomy for the treatment of chronic subdural hematomas and the use of the pre-coronal suture entry point 4).
The Subdural Evacuating Port System (SEPS), is a variation of the twist drill craniotomy (TDC) technique.
Burr hole washout is superior interns of clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings 5).
Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients.
Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization.
The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy 8).
Eighty-seven patients with CSDH underwent surgery at a institution from January 2004 to December 2008. The patients were classified into three groups according to the operative procedure; group I, one burr-hole craniostomy with closed system drainage with or without irrigation (n = 25), group II, two burr-hole craniostomy with closed system drainage with irrigation (n = 32), and group III, small craniotomy with irrigation and closed-system drainage (n = 30).
Age distribution, male and female ratio, Markwalder's grade on admission and at the time of discharge, size of hematoma before and after surgery, duration of operation, Hounsfield unit of hematoma before and after surgery, duration of hospital treatment, complication rate, and revision rate were categories that we compared between groups. Duration of operation and hospitalization were only two categories which were different. But, when comparing burr hole craniostomy group (group I and group II) with small craniotomy group (group III), duration of post-operative hospital treatment, complication and recurrence rate were statistically lower in small craniotomy group, even though operation time was longer.
Such results indicate that small craniotomy with irrigation and closed-system drainage can be considered as one of the treatment options in patients with CSDH 9).
A total of 42 patients treated with the burr hole craniotomy without irrigation with drainage were compared to 40 patients with irrigation and drainage. In both groups, univariate and multivariate analysis revealed that good clinical outcome was associated with preoperative Markwalder grade and the presence of postoperative hematoma recurrence. There was no difference in good outcome between the 2 operative methods.
There was no significant difference between these 2 operative techniques in relation to outcomes whether good or bad. The recurrence rate was 12.2%. When either technique is done properly, no difference to the outcome is seen. Neurosurgeons or general surgeons in Southeast Asia may choose not to irrigate the chronic subdural space, although drainage placement is necessary afterwards 10).
Gazzeri et al. present a technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, they inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma.
They used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%.
The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients 11).