ROLE OF SUBGALEAL VACUUM DRAINGAGE IN CHRONIC SUBDURAL HEMATOMA.
Objective: The aim of this study is to evaluate the level of safety and effectiveness of a subgaleal vacuum drain in chronic subdural haematoma.
Place and Duration of Study: In the department of Neurosurgery at CMH Rawalpindi from April 2012 to April 2014,
Study Design: Descriptive prospective study.
Material and Methods: The sampling technique was non-probability consecutive sampling. A calculated sample size was 110, by taking consecutive patients with chronic subdural haematoma (CSDH), who were treated with closed drainage system. Out of 110 patients, 10 patients were excluded on the basis of exclusion criteria. 100 patients below 85 years without gender discrimination were included in the study. Among the 10 excluded patients; 5 were critically ill and were above 85 years, 1 patient was below 5 years and 4 patients had craniotomy. Two burr holes were made on the maximum width of hematoma and subgaleal and subdural drains were placed. CT Scan was done on 5th post-surgical day for radiological evaluation.
Results: There were a total of 100 patients included in the study, 90 men and 10 women, ranging in age from 19 to 85 years (mean age, 63 +-15 years). The mean GCS at admission was 14 (+ 1). Out of total 100 patients, 88 (88%) patients had unilateral CSDH and 12(12%) had bilateral CSDH. In out of 88 patients with unilateral CSDH 44 (50%) and out of 12 with bilateral CSDH 6 (50%) subgaleal vacuum drain was placed. In 44 (50%) patients out of 88 with unilateral and 6 (50%) out of 12 bilateral CSDH, subdural simple drain was placed. The recurrence in either group was noted respectively. Among 50 patients with subgaleal drain only, 1(2.2%) patient out of 44 with unilateral CSDH and 1 (16.6%) patient out of 6 with bilateral CSDH had recurrence. Among 50 patients with simple subdural drain, 2 (4.5%) out of 44 patients with unilateral and 2(33%) out of 6 patients with bilateral CSDH had recurrence. The overall postoperative recurrence was in 6(6%) out of 100 patients.
The recurrence with subgaleal drain was in 2 patients (4%) out of 50 patients and with subdural drains 4 (8%) out of 50 patients respectively. Also, the recurrence rate was high in bilateral CSDH as compared to the unilateral hematoma. Out of 88, 2(2.2%) patients with unilateral and 4 (33%) out of 12 patients with bilateral CSDH had recurrence. A serious complication during this study was that 2 (4%) out of 50 patients with subdural drains had drain related cerebral cortical laceration and intra parenchymal bleed , one in male and one in female. Those patients were treated conservatively, whereas, no such complication was noted with subgaleal vacuum drain.
Conclusion: A sub galeal vacuum drain with two burr holes is sufficient to evacuate CSDH with lower recurrence rate.
Keywords: Burr-hole, Subdural hematoma, Subgaleal drain.
CSDH is the presence of liquefied blood within the subdural space lined by a pseudo membrane, after 3 weeks1. It mostly happens in the elderly population1. Treatment of choice is surgery2. Surgical techniques used are burr holes3. Burr hole is simple with low surgical risk and fairly effective. The reported recurrence rate ranges from 9.2 to 26.5% after surgical evacuation4. Different factors are associated with recurrence5. CSDH are evacuated and flushed via a single or two burr holes and frequently followed by closed-system drainage. Location of drains depends on neurosurgeon's choice. There are studies regarding efficacy and safety as regards to location of drains and use or no use of drains also6. Drains have the potential complications which make there use debatable. The aim of this study to assess the safety and postoperative recurrence between subgaleal vacuum drains and simple drains in CSDH.
MATERIAL AND METHODS
This descriptive prospective study was carried out prospectively at CMH Rawalpindi from April 2012 to April 2014. The sampling technique was non-probability consecutive sampling. A calculated sample size was 110 by taking consecutive patients with CSDH, who were treated with closed drainage system. Out of 110 patients, 10 patients were excluded on the basis of exclusion criteria. 100 patients below 85 years without gender discrimination were included. Among the 10 excluded patients; 5 were critically ill and were above 85 years, 1 patient was below 5 years and 4 patients had craniotomy Patients were usually elderly with usual symptoms of headache, low conscious level and neurological deficit. History of trauma and use of anticoagulants was present in some cases. Diagnosis was confirmed with CT Scan. Some patients had MRI in hand which was already done by the doctors.
Burr hole surgery was performed under general or local anesthesia depending on anesthetist evaluation. Subdural hematoma was evacuated by durotomy. Warm saline irrigation through a catheter or a syringe was done in each case until the irrigation return became clear. A catheter having numerous holes was placed extending from frontal to parietal burr hole through subgaleal space and out through a separate stab skin incision and secured. A vaccum suction bottle was attached to subgaleal drain in fifty patients. In another fifty patients soft nasogastric tubes were placed subdurally through frontal and parietal burr holes and connected to drainage bags without any suction. Post operatively patients were placed preferably in flat position for at least 24 hours. Drains were mostly removed within 3-5 days . Brain CT scans were performed post-operatively on fifth day and at final follow-up after one month in all cases.
The clinical criteria for recurrence included a change in mental status, deterioration or no improvement of the preexisting neurological deficit and new onset or aggravation of headache and a CT scans during the follow-up period revealing an increased subdural collection.
The results were calculated by statistical software SPSS version 21. Mean and SD were calculated for quantitative variables like age and GCS and categorical variables were presented by percentage and frequency.
There were a total of 100 patients included in the study, 90 men and 10 women in the study, ranging in age from 19 to 85 years (mean age, 63 +-15 years). The mean GCS at admission was 14 (+/-1). Out of total 100 patients, 88 (88%) patients had unilateral CSDH and 12(12%) had bilateral CSDH. Among 88 patients with unilateral CSDH 44 (50%) and out of 12 with bilateral CSDH 6 (50%), subgaleal vacuum drain was placed. In rest of 44 (50%) patients with unilateral and 6 (50%) bilateral CSDH, subdural simple drain was placed. The recurrence in either group was noted respectively. Among 50 patients with subgaleal drain only, 1(2.2%) patient out of 44 with unilateral CSDH and 1 (16.6%) patient out of 6 with bilateral CSDH had recurrence. Among 50 patients with simple subdural drain, 2 (4.5%) out of 44 patients with unilateral and 2(33%) out of 6 patients with bilateral CSDH had recurrence.
The overall postoperative recurrence was in 6 (6%) out of 100 patients. The recurrence with subgaleal drain was in 2 patients (4%) out of 50 patients and with subdural drains 4 (8%) out of 50 patients respectively. Also, the recurrence rate was high in bilateral CSDH as compared to the unilateral hematoma. Out of 88, 2(2.2%) patients with unilateral and 4 (33%) out of 12 patients with bilateral CSDH had recurrence. A serious complication during this study was that 2 (4%) out of 50 patients with subdural drains had drain related cerebral cortical laceration and intra parenchymal bleed , one in male and one in female. Those patients were treated conservatively, whereas, no such complication was noted with subgaleal vacuum drain.
CSDH generally occurs in elderly patients by a relatively trivial unnoticed trauma or spontaneously. The incidence of CSDH has been steadily increasing. This can be explained by the fact as the fraction of older population has increased7. The main aetiological factors are trauma, old age, brain atrophy, coagulopathy, fits and bilateral CSDH, higher hematoma density, postoperative air accumulation in sub dural space if simple drains are used8.
Haematoma begins by tearing of subdural bridging vessels and cortical surface lacerations causing accumulation of blood in subdural space. Clinical features may be headache, vomiting, low conscious level, fits and hemiparesis. Radiologically it is crescent shaped hypodensity area over cortical surface on CT scan9.
Surgery is the treatment of choice in most cases especially if symptomatic10. Burr holes are simple, quick and widely used technique with overall morbidity of 0 to 9%11,12. Craniotomy has greater morbidity but is still performed for a solid hematoma and multiple recurrences to remove blood and neo membrane13.
The main reasons for reoperation were residual thick hematoma membranes causing reaccumulation of subdural fluid due to residual hematoma or to re-bleeding14,15.
Burr-holes with closed-system drainage are used for treatment of CSDH16. Burr holes with subgaleal suction drain takes shorter operation time (fig-1) than subdural drains (fig-2). It has been reported previously that the irrigation through one burr hole is usually sufficient to wash out the hematoma in multiple cavities even if they are septated17. They concluded that in most cases of CSDH, multiplicity did not mean multiple closed cavities and that all hematoma cavities were in fact continuous with each other. In the previous study it was demonstrated that the catheter tip located in the frontal showed better surgical outcome in one burr craniostomy with closed-system drainage and irrigation18. According to another report which has compared closed-system drainage with irrigation with strict closed-system drainage in CSDH managements, and found five recurrences in the former and one in the latter group19.
Their result suggested that post-operative residual intra capsular air may be a factor of recurrence. In our study, patients operated on with burr holes and subgaleal vaccum suction drain had lower postoperative recurrence rate than those of two burr holes and subdural drains. The higher postoperative recurrence rate with subdural drains in a study was due to residual fluid and air. Another study reported that the persistence of the post-operative subdural cavity is a risk factor for reaccumulation of the hematoma and the presence of postoperative residual air prevents reduction of the cavity20. The explanation for higher recurrence rate is that the residual hematoma fluid due to non dependent craniostomy, contains large concentrations of vasoactive cytokines, inflammatory mediator and fibrinolytic factors. The complete evacuation of hematoma seems to be directly linked to the success of surgical procedure.
This is why in our study a subgaleal vaccum suction with two burr holes is more efficient to suck out subdural fluid collection with minimal recurrence21,22.
One serious complication during this study was that two patients with subdural drains had drain related cerebral cortical laceration and intra parenchymal bleed each one in male and one in female. These patients were treated conservatively.
We conclude that CSDH can be efficiently and safely evacuated by a subgaleal suction drains which is less invasive procedure, with lower recurrence rate and less drain related complications.
CONFLICT OF INTEREST
The authors of this study reported no conflict of interest.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Article Type:||Clinical report|
|Date:||Feb 29, 2016|
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