[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal
Editorial
Closed drainage following surgery for chronic subdural hematoma: Complacency causes critical lapses Sanjay Behari Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Sanjay Behari, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 226 014, Uttar Pradesh, India. E-mail: [email protected] Received Review completed Accepted
: 10-04-2014 : 10-04-2014 : 13-04-2014
Surgical evacuation of a chronic subdural hematoma (CSDH) represents one of the most gratifying procedures in neurosurgery. Patients usually recover in the shortest possible time with minimum degree of difficulty when compared with most other neurosurgical procedures. Ironically, despite the high incidence of a CSDH, [1] its evacuation also represents the second-most neglected neurosurgical procedure (the first being ventriculoperitoneal shunt surgery) in the current neurosurgical practice. The procedure is often unsupervised and carried out under local anesthesia or regional blocks, by the junior-most members of the neurosurgical team at unearthly hours, usually in elderly patients with significant life-threatening comorbidities, who may also be on anticoagulants.[2] In this study, “A prospective randomized study of use of drain versus no drain after burr-hole evacuation of chronic subdural hematoma,” the authors have done Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.132316
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
yeoman’s service by scientifically investigating the need for a closed drainage following a CSDH evacuation. They highlight the dilemma encountered while navigating the narrow strait between “the Scylla” of recurrence of a CSDH (in 3.1-33% patients) by not placing a postoperative closed subdural drain; and “the Charybdis” of a higher risk of an empyema (in approximately 2.1% patients) or a cortical or subdural venous injury occurring by instituting the drainage.[1] The emerging message is clear and unequivocal. Placement of a closed subdural drain significantly reduces the recurrence rate of a CSDH while not influencing the overall morbidity and mortality statistics. Of greater import is the observation that there is a drastic decrease in the reoperation rates within 6 months of the original drainage procedure. A reduction in reoperation procedures decreases the risk of infection manifolds.[2-6] A few other advantages of a closed subdural drain need to be emphasized. An undetected, residual or recurrent CSDH may continue to exert mass effect and its membranes may undergo fibrosis or even calcification. A craniotomy may be mandated to reverse the persistent neurological deficits.[3] The rupture of the stretched veins due to the widened subdural space in proximity to the residual CSDH may precipitate an acute subdural hematoma (SDH) or even a cortical venous infarction. The oncotic pressure of the contents of the residual 121
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Behari: Closed drainage for chronic subdural hematoma
SDH may be high; the fragile walls of the CSDH have a predisposition to recurrent hemorrhages. The silent re-expansion of residual/recurrent CSDH by osmotic ingress of fluid or membranous bleed may lead to a catastrophic transtentorial herniation.[2] The premonitory signs (such as altered sensorium and ipsilateral pupillary dilatation) may often go undetected due to the coexisting dementia, electrolyte imbalance, medical conditions, and social neglect of elderly patients. A persistent subcutaneous seepage of the residual CSDH usually occurs through the open dural leaves and the outer SDH membrane following its burr-hole evacuation. A closed drainage is, however, essential when an alternative minimally invasive procedure like a twist-drill drainage is being utilized.[3] The more frequently encountered an entity, the greater attention it generates and consequently, sharper is the scrutiny over its finer nuances. CSDH exemplifies one such condition where every management issue has been dissected threadbare. Consequentially, matters left unaddressed in a study are immediately obvious. Bilateral CSDH is one such issue that requires further discussion due to its fairly common occurrence. Whenever burr-hole evacuation of a bilateral CSDH is being performed, the dura should be opened simultaneously on both sides in order to avoid a rapid, unilateral decompression of the CSDH and precipitation of a sudden subfalcine herniation. The single case in the authors’ series with a bilateral CSDH underwent closed subdural drainage on both sides following its surgical evacuation.[1] However, in patients with grossly asymmetrical, bilateral CSDH accumulation, the issue has not been unequivocally resolved. A unilateral closed drainage on the side with the larger volume, although appropriate in this situation, may precipitate a rapid increase in the size of the contralateral SDH. A serial follow-up with computed tomography (CT) scans and a bilateral, closed subdural drainage may still be required either concurrently or in a staged manner in this situation. Often a bilateral, isodense CSDH (especially in the presence of anemia) may be overlooked unless a contrast imaging study delineates the leptomeningeal membrane that serves as the defining border between the brain and the isodense CSDH. The authors state that they never prolong the duration of drainage beyond 48 h.[1] Perhaps, a more prudent approach would be to decide on a patient-to-patient basis. If the plain CT scan performed after 48 h shows a persistent CSDH causing mass effect, the closed subdural drainage would require continuance; the possibility of a thick persistent CSDH membrane should also be considered. Recalcitrant CSDH in the presence of a cerebrospinal fluid diversion procedure is another vexing issue. Perhaps a subduroperitoneal shunt 122
following surgical evacuation may be the appropriate solution in clinically symptomatic cases. In persistent cases, an antisiphon devise may have to be placed in the shunt system to prevent cerebrospinal fluid over drainage and the consequent expansion of the subdural space due to brain shrinkage. The situation of a rapidly expanding brain following drainage of a CSDH has been alluded to in the study only to be excluded.[1] An immediate postoperative CT scan to rule out edema or a hematoma in the rapidly expanding brain should always be kept in mind. One should be open-minded in accepting the need to administer steroids/dehydrants under these circumstances. The inability of the brain to re-expand following a CSDH evacuation also correlates with recurrence rate. In the study by Mori and Maeda, the brain re-expansion rate at 1 week, after operation, was 45.0 ± 21.4% in patients with hematoma recurrence and significantly lower than 55.3 ± 19.1% in patients without recurrence (P < 0.001). Old age, preexisting cerebral infarction, and persistence of subdural air after surgery were significantly correlated with poor brain re-expansion (P < 0.001).[4] In this article, the difference in the incidence of subdural empyema in the two groups (with or without a postoperative closed subdural drainage) did not attain statistical significance.[1] A subdural empyema may closely resemble a persistent CSDH unless a high index of suspicion is maintained. Its early detection avoids the development of complications such as cerebral abscess, cortical venous thrombosis, or localized cerebritis.[7] Any sign of infection and lack of clinical improvement should mandate an immediate contrast CT scan. The authors have not clarified if following the detection of the subdural empyema, a closed subdural drainage (with continuous irrigation of the subdural space through the inlet and egress of the effluent through the outlet drains) under the cover of antibiotics was instituted for a prolonged period in these patients. The final point perhaps requires the greatest thought. A residual CSDH, more often than not, remains asymptomatic and gets absorbed over time. Should every residual CSDH, even when clinically insignificant, be treated with a closed drainage? Perhaps, utilizing discretion, a large CSDH with significant neurological compromise, presence of a thick membrane, an acute-on-chronic hematoma, a CSDH with infection or a multi-loculated SDH are situations where a closed drain becomes mandatory following the definitive surgery.[2,6] The article under the lens is not a seminal study. Several other authors have prospectively dealt with this issue.[2-6] What is striking from a review of literature, however, is the uniformity of the emergent message and its far-reaching impact on the management of this common ailment. This Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Behari: Closed drainage for chronic subdural hematoma
study as well as the ones preceding it emphasize how little is the attention being paid to the introduction of a simple modification (placement of a closed subdural drain) in the routine technique of burr-hole evacuation of a CSDH that may lead to a significant decrease in the recurrence rates and consequently, of the reoperation rates.
3.
References
6.
1.
7.
Singh AK, Suryanarayanan B, Choudhary A, Prasad A, Singh S, Gupta LN. A prospective randomized study of use of drain versus no drain after burr hole evacuation of chronic subdural hematoma. Neurol India 2014;62:169-74. Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, et al. Chronic subdural hematoma management: A systematic review and meta-analysis of 34,829 patients. Ann Surg 2014;259:449-57.
2.
4. 5.
Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: Evidence based review. J Neurol Neurosurg Psychiatry 2003;74:937-43. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001;41:371-81. Markwalder TM. The course of chronic subdural hematomas after burr-hole craniostomy with and without closed-system drainage. Neurosurg Clin N Am 2000;11:541-6. Sambasivan M. An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol 1997;47:418-22. Ovalioglu AO, Aydin OA. A case of subdural empyema following chronic subdural hematoma drainage. Neurol India 2013;61:207-9.7.
How to cite this article: Behari S. Closed drainage following surgery for chronic subdural hematoma: Complacency causes critical lapses. Neurol India 2014;62:121-3. Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Online submission of the manuscripts Articles can be submitted online from http://www.journalonweb.com. For online submission, the articles should be prepared in two files (first page file and article file). Images should be submitted separately. 1) 2)
3)
4)
First Page File: Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity should be included here. Use text/rtf/doc/pdf files. Do not zip the files. Article File: The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any information (such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size to 1 MB. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being incorporated in the article file. This will reduce the size of the file. Images: Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by decreasing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most suitable file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always retain a good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised article. Legends: Legends for the figures/images should be included at the end of the article file.
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
123
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Closed drainage following surgery for chronic subdural hematoma: Complacency causes critical lapses Sanjay Behari Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Sanjay Behari, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 226 014, Uttar Pradesh, India. E-mail: [email protected] Received Review completed Accepted
: 10-04-2014 : 10-04-2014 : 13-04-2014
Surgical evacuation of a chronic subdural hematoma (CSDH) represents one of the most gratifying procedures in neurosurgery. Patients usually recover in the shortest possible time with minimum degree of difficulty when compared with most other neurosurgical procedures. Ironically, despite the high incidence of a CSDH, [1] its evacuation also represents the second-most neglected neurosurgical procedure (the first being ventriculoperitoneal shunt surgery) in the current neurosurgical practice. The procedure is often unsupervised and carried out under local anesthesia or regional blocks, by the junior-most members of the neurosurgical team at unearthly hours, usually in elderly patients with significant life-threatening comorbidities, who may also be on anticoagulants.[2] In this study, “A prospective randomized study of use of drain versus no drain after burr-hole evacuation of chronic subdural hematoma,” the authors have done Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.132316
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
yeoman’s service by scientifically investigating the need for a closed drainage following a CSDH evacuation. They highlight the dilemma encountered while navigating the narrow strait between “the Scylla” of recurrence of a CSDH (in 3.1-33% patients) by not placing a postoperative closed subdural drain; and “the Charybdis” of a higher risk of an empyema (in approximately 2.1% patients) or a cortical or subdural venous injury occurring by instituting the drainage.[1] The emerging message is clear and unequivocal. Placement of a closed subdural drain significantly reduces the recurrence rate of a CSDH while not influencing the overall morbidity and mortality statistics. Of greater import is the observation that there is a drastic decrease in the reoperation rates within 6 months of the original drainage procedure. A reduction in reoperation procedures decreases the risk of infection manifolds.[2-6] A few other advantages of a closed subdural drain need to be emphasized. An undetected, residual or recurrent CSDH may continue to exert mass effect and its membranes may undergo fibrosis or even calcification. A craniotomy may be mandated to reverse the persistent neurological deficits.[3] The rupture of the stretched veins due to the widened subdural space in proximity to the residual CSDH may precipitate an acute subdural hematoma (SDH) or even a cortical venous infarction. The oncotic pressure of the contents of the residual 121
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Behari: Closed drainage for chronic subdural hematoma
SDH may be high; the fragile walls of the CSDH have a predisposition to recurrent hemorrhages. The silent re-expansion of residual/recurrent CSDH by osmotic ingress of fluid or membranous bleed may lead to a catastrophic transtentorial herniation.[2] The premonitory signs (such as altered sensorium and ipsilateral pupillary dilatation) may often go undetected due to the coexisting dementia, electrolyte imbalance, medical conditions, and social neglect of elderly patients. A persistent subcutaneous seepage of the residual CSDH usually occurs through the open dural leaves and the outer SDH membrane following its burr-hole evacuation. A closed drainage is, however, essential when an alternative minimally invasive procedure like a twist-drill drainage is being utilized.[3] The more frequently encountered an entity, the greater attention it generates and consequently, sharper is the scrutiny over its finer nuances. CSDH exemplifies one such condition where every management issue has been dissected threadbare. Consequentially, matters left unaddressed in a study are immediately obvious. Bilateral CSDH is one such issue that requires further discussion due to its fairly common occurrence. Whenever burr-hole evacuation of a bilateral CSDH is being performed, the dura should be opened simultaneously on both sides in order to avoid a rapid, unilateral decompression of the CSDH and precipitation of a sudden subfalcine herniation. The single case in the authors’ series with a bilateral CSDH underwent closed subdural drainage on both sides following its surgical evacuation.[1] However, in patients with grossly asymmetrical, bilateral CSDH accumulation, the issue has not been unequivocally resolved. A unilateral closed drainage on the side with the larger volume, although appropriate in this situation, may precipitate a rapid increase in the size of the contralateral SDH. A serial follow-up with computed tomography (CT) scans and a bilateral, closed subdural drainage may still be required either concurrently or in a staged manner in this situation. Often a bilateral, isodense CSDH (especially in the presence of anemia) may be overlooked unless a contrast imaging study delineates the leptomeningeal membrane that serves as the defining border between the brain and the isodense CSDH. The authors state that they never prolong the duration of drainage beyond 48 h.[1] Perhaps, a more prudent approach would be to decide on a patient-to-patient basis. If the plain CT scan performed after 48 h shows a persistent CSDH causing mass effect, the closed subdural drainage would require continuance; the possibility of a thick persistent CSDH membrane should also be considered. Recalcitrant CSDH in the presence of a cerebrospinal fluid diversion procedure is another vexing issue. Perhaps a subduroperitoneal shunt 122
following surgical evacuation may be the appropriate solution in clinically symptomatic cases. In persistent cases, an antisiphon devise may have to be placed in the shunt system to prevent cerebrospinal fluid over drainage and the consequent expansion of the subdural space due to brain shrinkage. The situation of a rapidly expanding brain following drainage of a CSDH has been alluded to in the study only to be excluded.[1] An immediate postoperative CT scan to rule out edema or a hematoma in the rapidly expanding brain should always be kept in mind. One should be open-minded in accepting the need to administer steroids/dehydrants under these circumstances. The inability of the brain to re-expand following a CSDH evacuation also correlates with recurrence rate. In the study by Mori and Maeda, the brain re-expansion rate at 1 week, after operation, was 45.0 ± 21.4% in patients with hematoma recurrence and significantly lower than 55.3 ± 19.1% in patients without recurrence (P < 0.001). Old age, preexisting cerebral infarction, and persistence of subdural air after surgery were significantly correlated with poor brain re-expansion (P < 0.001).[4] In this article, the difference in the incidence of subdural empyema in the two groups (with or without a postoperative closed subdural drainage) did not attain statistical significance.[1] A subdural empyema may closely resemble a persistent CSDH unless a high index of suspicion is maintained. Its early detection avoids the development of complications such as cerebral abscess, cortical venous thrombosis, or localized cerebritis.[7] Any sign of infection and lack of clinical improvement should mandate an immediate contrast CT scan. The authors have not clarified if following the detection of the subdural empyema, a closed subdural drainage (with continuous irrigation of the subdural space through the inlet and egress of the effluent through the outlet drains) under the cover of antibiotics was instituted for a prolonged period in these patients. The final point perhaps requires the greatest thought. A residual CSDH, more often than not, remains asymptomatic and gets absorbed over time. Should every residual CSDH, even when clinically insignificant, be treated with a closed drainage? Perhaps, utilizing discretion, a large CSDH with significant neurological compromise, presence of a thick membrane, an acute-on-chronic hematoma, a CSDH with infection or a multi-loculated SDH are situations where a closed drain becomes mandatory following the definitive surgery.[2,6] The article under the lens is not a seminal study. Several other authors have prospectively dealt with this issue.[2-6] What is striking from a review of literature, however, is the uniformity of the emergent message and its far-reaching impact on the management of this common ailment. This Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
[Downloaded free from http://www.neurologyindia.com on Thursday, May 15, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Behari: Closed drainage for chronic subdural hematoma
study as well as the ones preceding it emphasize how little is the attention being paid to the introduction of a simple modification (placement of a closed subdural drain) in the routine technique of burr-hole evacuation of a CSDH that may lead to a significant decrease in the recurrence rates and consequently, of the reoperation rates.
3.
References
6.
1.
7.
Singh AK, Suryanarayanan B, Choudhary A, Prasad A, Singh S, Gupta LN. A prospective randomized study of use of drain versus no drain after burr hole evacuation of chronic subdural hematoma. Neurol India 2014;62:169-74. Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, et al. Chronic subdural hematoma management: A systematic review and meta-analysis of 34,829 patients. Ann Surg 2014;259:449-57.
2.
4. 5.
Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: Evidence based review. J Neurol Neurosurg Psychiatry 2003;74:937-43. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001;41:371-81. Markwalder TM. The course of chronic subdural hematomas after burr-hole craniostomy with and without closed-system drainage. Neurosurg Clin N Am 2000;11:541-6. Sambasivan M. An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol 1997;47:418-22. Ovalioglu AO, Aydin OA. A case of subdural empyema following chronic subdural hematoma drainage. Neurol India 2013;61:207-9.7.
How to cite this article: Behari S. Closed drainage following surgery for chronic subdural hematoma: Complacency causes critical lapses. Neurol India 2014;62:121-3. Source of Support: Nil, Conflict of Interest: None declared.
Author Help: Online submission of the manuscripts Articles can be submitted online from http://www.journalonweb.com. For online submission, the articles should be prepared in two files (first page file and article file). Images should be submitted separately. 1) 2)
3)
4)
First Page File: Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity should be included here. Use text/rtf/doc/pdf files. Do not zip the files. Article File: The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any information (such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size to 1 MB. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being incorporated in the article file. This will reduce the size of the file. Images: Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by decreasing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most suitable file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always retain a good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised article. Legends: Legends for the figures/images should be included at the end of the article file.
Neurology India | Mar-Apr 2014 | Vol 62 | Issue 2
123
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
