Subdural versus subgaleal drainage for chronic subdural hematomas: a post hoc analysis of the TOSCAN trial

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  • 1 Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern;
  • 2 Clinical Trials Unit Bern, University of Bern, Switzerland;
  • 3 Department of Neurosurgery, Medical Center–University of Freiburg, Germany; and
  • 4 Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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OBJECTIVE

The use of subdural drains after surgical evacuation of chronic subdural hematoma (CSH) decreases the risk of recurrence and has become the standard of care. Halfway through the controlled, randomized TOSCAN (Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma) trial, the authors’ institutional guidelines changed to recommend subgaleal instead of subdural drainage. The authors report a post hoc analysis on the influence of drain location in patients participating in the TOSCAN trial.

METHODS

The study involved 361 patients enrolled in the TOSCAN trial. The patients were stratified according to whether they received surgery before (cohort A) or after (cohort B) the change in institutional protocol. An intention-to-treat analysis was performed with surgery for recurrence as the primary endpoint. Secondary endpoints were outcome-based on modified Rankin Scale scores, seizures, infections, parenchymal brain injuries, and hematoma diameter.

RESULTS

Of the 361 patients included in the analysis, 214 were stratified into cohort A (subdural drainage recommended), while 147 were stratified into cohort B (subgaleal drainage recommended). There was a 31.78% rate of crossover from the subdural to the subgaleal drainage insertion site due to technical or anatomical difficulties. No differences in the rates of reoperation (21.5% [cohort A] vs 25.17% [cohort B], OR 0.81, 95% CI 0.50–1.34, p = 0.415), infections (0.47% [cohort A] vs 2.04% [cohort B], OR 0.23, 95% CI 0.02–2.19, p = 0.199), seizures (3.27% [cohort A] vs 2.72% [cohort B], OR 1.21, 95% CI 0.35–4.21, p = 0.765), or favorable outcomes (modified Rankin Scale score 0–3) at 1 and 6 months (91.26% [cohort A] vs 96.43% [cohort B], OR 0.39, 95% CI 0.14–1.07, p = 0.067; 89.90% [cohort A] vs 91.55% [cohort B], OR 0.82, 95% CI 0.39–1.73, p = 0.605) were noted between the two cohorts. Postoperatively, patients in cohort A had more frequent parenchymal brain tissue injuries (2.8% vs 0%, p = 0.041). Postoperative absolute and relative hematoma reduction was similar irrespective of the location of the drain.

CONCLUSIONS

Subgaleal rather than subdural placement of the drain did not increase the risk for reoperation for recurrence of CSHs, nor did it have a negative impact on clinical or radiological outcome. The intention to place a subdural drain was associated with a higher rate of parenchymal injuries.

ABBREVIATIONS CI = confidence interval; CSH = chronic subdural hematoma; mRS = modified Rankin Scale; NIHSS = NIH Stroke Scale; OR = odds ratio; TOSCAN = Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma.

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Contributor Notes

Correspondence Philippe Schucht: Inselspital Bern, Switzerland. philippe.schucht@insel.ch.

INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.5.JNS19858.

L.H. and S.V. contributed equally to this work.

Disclosures Dr. Schucht reports direct stock ownership in Trustedoctor, being a board member for Trustedoctor, and being a consultant for Ideogen and Integra.

  • 1

    Ahmed S, Agarwal D, Kale SS, Mahapatra AK: A comparative study of treatment of chronic subdural hematoma—burr hole drainage versus continuous closed drainage. Indian J Neurotrauma 8:1724, 2011

    • Search Google Scholar
    • Export Citation
  • 2

    Alcalá-Cerra G, Young AM, Moscote-Salazar LR, Paternina-Caicedo A: Efficacy and safety of subdural drains after burr-hole evacuation of chronic subdural hematomas: systematic review and meta-analysis of randomized controlled trials. World Neurosurg 82:11481157, 2014

    • Search Google Scholar
    • Export Citation
  • 3

    Bellut D, Woernle CM, Burkhardt JK, Kockro RA, Bertalanffy H, Krayenbühl N: Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas. World Neurosurg 77:111118, 2012

    • Search Google Scholar
    • Export Citation
  • 4

    Brennan PM, Kolias AG, Joannides AJ, Shapey J, Marcus HJ, Gregson BA, : The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg 127:732739, 2017

    • Search Google Scholar
    • Export Citation
  • 5

    Erol FS, Topsakal C, Faik Ozveren M, Kaplan M, Tiftikci MT: Irrigation vs. closed drainage in the treatment of chronic subdural hematoma. J Clin Neurosci 12:261263, 2005

    • Search Google Scholar
    • Export Citation
  • 6

    Han MH, Ryu JI, Kim CH, Kim JM, Cheong JH, Yi HJ: Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma. J Neurosurg 127:11171125, 2017

    • Search Google Scholar
    • Export Citation
  • 7

    Horn EM, Feiz-Erfan I, Bristol RE, Spetzler RF, Harrington TR: Bedside twist drill craniostomy for chronic subdural hematoma: a comparative study. Surg Neurol 65:150154, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Javadi A, Amirjamshidi A, Aran S, Hosseini SH: 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, 620623, 2011

    • Search Google Scholar
    • Export Citation
  • 9

    Kaliaperumal C, Khalil A, Fenton E, Okafo U, Kaar G, O’Sullivan M, : A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma. Acta Neurochir (Wien) 154:20832089, 2012

    • Search Google Scholar
    • Export Citation
  • 10

    Kolias AG, Chari A, Santarius T, Hutchinson PJ: Chronic subdural haematoma: modern management and emerging therapies. Nat Rev Neurol 10:570578, 2014

    • Search Google Scholar
    • Export Citation
  • 11

    Lind CRP, Lind CJ, Mee EW: Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains. J Neurosurg 99:4446, 2003

    • Search Google Scholar
    • Export Citation
  • 12

    Liu W, Bakker NA, Groen RJM: Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121:665673, 2014

    • Search Google Scholar
    • Export Citation
  • 13

    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) 41:371381, 2001

    • Search Google Scholar
    • Export Citation
  • 14

    Pang CH, Lee SE, Kim CH, Kim JE, Kang HS, Park CK, : Acute intracranial bleeding and recurrence after bur hole craniostomy for chronic subdural hematoma. J Neurosurg 123:6574, 2015

    • Search Google Scholar
    • Export Citation
  • 15

    Sambasivan M: An overview of chronic subdural hematoma: experience with 2300 cases. Surg Neurol 47:418422, 1997

  • 16

    Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, : Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet 374:10671073, 2009

    • Search Google Scholar
    • Export Citation
  • 17

    Schucht P, Fischer U, Fung C, Bernasconi C, Fichtner J, Vulcu S, : Follow-up computed tomography after evacuation of chronic subdural hematoma. N Engl J Med 380:11861187, 2019

    • Search Google Scholar
    • Export Citation
  • 18

    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 62:169174, 2014

    • Search Google Scholar
    • Export Citation
  • 19

    Sjåvik K, Bartek J Jr, Sagberg LM, Henriksen ML, Gulati S, Ståhl FL, : Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study. J Neurosurg [epub ahead of print June 23, 2017. DOI: 10.3171/2016.12.JNS161713]

    • Search Google Scholar
    • Export Citation
  • 20

    Smely C, Madlinger A, Scheremet R: Chronic subdural haematoma—a comparison of two different treatment modalities. Acta Neurochir (Wien) 139:818826, 1997

    • Search Google Scholar
    • Export Citation
  • 21

    Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M, Yamagata S: Independent predictors for recurrence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery 63:11251129, 2008

    • Search Google Scholar
    • Export Citation
  • 22

    Unterhofer C, Freyschlag CF, Thomé C, Ortler M: Opening the internal hematoma membrane does not alter the recurrence rate of chronic subdural hematomas: a prospective randomized trial. World Neurosurg 92:3136, 2016

    • Search Google Scholar
    • Export Citation
  • 23

    Wakai S, Hashimoto K, Watanabe N, Inoh S, Ochiai C, Nagai M: Efficacy of closed-system drainage in treating chronic subdural hematoma: a prospective comparative study. Neurosurgery 26:771773, 1990

    • Search Google Scholar
    • Export Citation
  • 24

    Weigel R, Schmiedek P, Krauss JK: Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:937943, 2003

    • Search Google Scholar
    • Export Citation
  • 25

    Zumofen D, Regli L, Levivier M, Krayenbühl N: Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery 64:11161122, 2009

    • Search Google Scholar
    • Export Citation

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