International practice variation in postoperative imaging of chronic subdural hematoma patients

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OBJECTIVE

The value of CT scanning after burr hole surgery in chronic subdural hematoma (CSDH) patients is unclear, and practice differs between countries. At the Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, neurosurgeons frequently order routine postoperative CT scans, while the University Medical Center Utrecht (UMCU) in the Netherlands does not have this policy. The aim of this study was to compare the use of postoperative CT scans in CSDH patients between these hospitals and to evaluate whether there are differences in clinical outcomes.

METHODS

The authors collected data from both centers for 391 age- and sex-matched CSDH patients treated with burr hole surgery between January 1, 2002, and July 1, 2016, and compared the number of postoperative scans up to 6 weeks after surgery, the need for re-intervention, and postoperative neurological condition.

RESULTS

BWH patients were postoperatively scanned a median of 4 times (interquartile range [IQR] 2–5), whereas UMCU patients underwent a median of 0 scans (IQR 0–1, p < 0.001). There was no significant difference in the number of re-operations (20 in the BWH vs 27 in the UMCU, p = 0.34). All re-interventions were preceded by clinical decline and no recurrences were detected on scans performed on asymptomatic patients. Patients’ neurological condition was not worse in the UMCU than in the BWH (p = 0.43).

CONCLUSIONS

While BWH patients underwent more scans than UMCU patients, there were no differences in clinical outcomes. The results of this study suggest that there is little benefit to routine scanning in asymptomatic patients who have undergone surgical treatment of uncomplicated CSDH and highlight opportunities to make practice more efficient.

ABBREVIATIONS BWH = Brigham and Women’s Hospital; CSDH = chronic subdural hematoma; CT = computed tomography; IQR = interquartile range; UMCU = University Medical Center Utrecht.
Article Information

Contributor Notes

Correspondence Marike L. D. Broekman: Leiden University Medical Center, Leiden University, Leiden, The Netherlands. marikebroekman@gmail.com.INCLUDE WHEN CITING Published online December 21, 2018; DOI: 10.3171/2018.8.JNS181767.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Adhiyaman VAsghar MGaneshram KNBhowmick BK: Chronic subdural haematoma in the elderly. Postgrad Med J 78:71752002

  • 2

    Avanali RBhadran BKrishna Kumar PVijayan AArun SMusthafa AM: Chronic subdural hematoma: a questionnaire survey of management practice in India and review of literature. World Neurosurg 96:3553612016

    • Search Google Scholar
    • Export Citation
  • 3

    Benveniste RJFerraro NTsimpas A: Yield and utility of routine postoperative imaging after resection of brain metastases. J Neurooncol 118:3633672014

    • Search Google Scholar
    • Export Citation
  • 4

    Berghauser Pont LMDippel DWVerweij BHDirven CMDammers R: Ambivalence among neurologists and neurosurgeons on the treatment of chronic subdural hematoma: a national survey. Acta Neurol Belg 113:55592013

    • Search Google Scholar
    • Export Citation
  • 5

    Binning MRagel BBrockmeyer DLWalker MLKestle JR: Evaluation of the necessity of postoperative imaging after craniosynostosis surgery. J Neurosurg 107 (1 Suppl):43452007

    • Search Google Scholar
    • Export Citation
  • 6

    Brenner DJ: Should we be concerned about the rapid increase in CT usage? Rev Environ Health 25:63682010

  • 7

    Carrier ERReschovsky JDKatz DAMello MM: High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Aff (Millwood) 32:138313912013

    • Search Google Scholar
    • Export Citation
  • 8

    Cenic ABhandari MReddy K: Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci 32:5015062005

    • Search Google Scholar
    • Export Citation
  • 9

    Ducruet AFGrobelny BTZacharia BEHickman ZLDeRosa PLAndersen KN: The surgical management of chronic subdural hematoma. Neurosurg Rev 35:1551692012 (Erratum in Neurosurg Rev 38:771 2015)

    • Search Google Scholar
    • Export Citation
  • 10

    Dudoit TLabeyrie PEDeryckere SEmery EGaberel T: Is systematic post-operative CT scan indicated after chronic subdural hematoma surgery? A case-control study. Acta Neurochir (Wien) 158:124112462016

    • Search Google Scholar
    • Export Citation
  • 11

    Engel GL: The need for a new medical model: a challenge for biomedicine. Science 196:1291361977

  • 12

    Foelholm RWaltimo O: Epidemiology of chronic subdural haematoma. Acta Neurochir (Wien) 32:2472501975

  • 13

    Garrett MCBilgin-Freiert ABartels CEverson RAfsarmanesh NPouratian N: An evidence-based approach to the efficient use of computed tomography imaging in the neurosurgical patient. Neurosurgery 73:2092162013

    • Search Google Scholar
    • Export Citation
  • 14

    Geßler FDützmann SQuick JTizi KVoigt MAMutlak H: Is postoperative imaging mandatory after meningioma removal? Results of a prospective study. PLoS One 10:e01245342015

    • Search Google Scholar
    • Export Citation
  • 15

    Halevi PDUdayakumaran SBen-Sira LConstantini S: The value of postoperative MR in tethered cord: a review of 140 cases. Childs Nerv Syst 27:215921622011

    • Search Google Scholar
    • Export Citation
  • 16

    Ioannidis JPPrasad V: Evaluating health system processes with randomized controlled trials. JAMA Intern Med 173:127912802013

  • 17

    Jiang ZYAllen KKutz JW JrIsaacson B: Clinical impact of early CT scans after lateral skull-base surgery. Otolaryngol Head Neck Surg 149:7867882013

    • Search Google Scholar
    • Export Citation
  • 18

    Khaldi APrabhu VCAnderson DEOrigitano TC: The clinical significance and optimal timing of postoperative computed tomography following cranial surgery. J Neurosurg 113:102110252010

    • Search Google Scholar
    • Export Citation
  • 19

    Kroneman MBoerma Wvan den Berg MGroenewegen Pde Jong Jvan Ginneken E: Netherlands: health system review. Health Syst Transit 18:12402016

    • Search Google Scholar
    • Export Citation
  • 20

    Macleod MRMichie SRoberts IDirnagl UChalmers IIoannidis JP: Biomedical research: increasing value, reducing waste. Lancet 383:1011042014

    • Search Google Scholar
    • Export Citation
  • 21

    Nadimi SCaballero NCarpenter PSowa LCunningham RWelch KC: Immediate postoperative imaging after uncomplicated endoscopic approach to the anterior skull base: is it necessary? Int Forum Allergy Rhinol 4:102410292014

    • Search Google Scholar
    • Export Citation
  • 22

    Nakaguchi HTanishima TYoshimasu N: Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage. J Neurosurg 93:7917952000

    • Search Google Scholar
    • Export Citation
  • 23

    Office of Technology Assessment: Defensive Medicine and Medical Malpractice OTA-H--602. Washington, DC: U.S. Government Printing Office1994

    • Search Google Scholar
    • Export Citation
  • 24

    Oh HJLee KSShim JJYoon SMYun IGBae HG: Postoperative course and recurrence of chronic subdural hematoma. J Korean Neurosurg Soc 48:5185232010

    • Search Google Scholar
    • Export Citation
  • 25

    Paul ABOklu RSaini SPrabhakar AM: How much is that head CT? Price transparency and variability in radiology. J Am Coll Radiol 12:4534572015

    • Search Google Scholar
    • Export Citation
  • 26

    Pedersen CBSundbye FPoulsen FR: No value of routine brain computed tomography 6 weeks after evacuation of chronic subdural hematoma. Surg J (N Y) 3:e174e1762017

    • Search Google Scholar
    • Export Citation
  • 27

    Pencalet P: [Clinical forms and prognostic factors of chronic subdural hematoma in the adult.] Neurochirurgie 47:4694722001 (Fr)

  • 28

    Peng DZhu Y: External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults. Cochrane Database Syst Rev (8):CD0114022016

    • Search Google Scholar
    • Export Citation
  • 29

    Ro HWPark SKJang DKYoon WSJang KSHan YM: Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma. Acta Neurochir (Wien) 158:1351392016

    • Search Google Scholar
    • Export Citation
  • 30

    Rovlias ATheodoropoulos SPapoutsakis D: Chronic subdural hematoma: Surgical management and outcome in 986 cases: a classification and regression tree approach. Surg Neurol Int 6:1272015

    • Search Google Scholar
    • Export Citation
  • 31

    Saini VGarcia-Armesto SKlemperer DParis VElshaug AGBrownlee S: Drivers of poor medical care. Lancet 390:1781902017

  • 32

    Santarius THutchinson PJ: Chronic subdural haematoma: time to rationalize treatment? Br J Neurosurg 18:3283322004

  • 33

    Santarius TLawton RKirkpatrick PJHutchinson PJ: The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 22:5295342008

    • Search Google Scholar
    • Export Citation
  • 34

    Schär RTFiechter MZ’Graggen WJSöll NKrejci VWiest R: No routine postoperative head CT following elective craniotomy—a paradigm shift? PLoS One 11:e01534992016

    • Search Google Scholar
    • Export Citation
  • 35

    Smith TRHabib ARosenow JMNahed BVBabu MACybulski G: Defensive medicine in neurosurgery: does state-level liability risk matter? Neurosurgery 76:1051142015

    • Search Google Scholar
    • Export Citation
  • 36

    Smith TRHulou MMYan SCCote DJNahed BVBabu MA: Defensive medicine in neurosurgery: the Canadian experience. J Neurosurg 124:152415302016

    • Search Google Scholar
    • Export Citation
  • 37

    Squires DA: Explaining high health care spending in the United States: an international comparison of supply, utilization, prices, and quality. Issue Brief (Commonw Fund) 10:1142012

    • Search Google Scholar
    • Export Citation
  • 38

    Stippler MSmith CMcLean ARCarlson AMorley SMurray-Krezan C: Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J 29:5285322012

    • Search Google Scholar
    • Export Citation
  • 39

    Teles ARFalavigna AKraemer J: Surgical treatment of chronic subdural hematoma: systematic review and meta-analysis of the literature. Arq Bras Neurocir 35:1181272016

    • Search Google Scholar
    • Export Citation
  • 40

    Wada MYamakami IHiguchi YTanaka MSuda SOno J: Influence of antiplatelet therapy on postoperative recurrence of chronic subdural hematoma: a multicenter retrospective study in 719 patients. Clin Neurol Neurosurg 120:49542014

    • Search Google Scholar
    • Export Citation
  • 41

    Weigel RSchmiedek PKrauss JK: Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:9379432003

    • Search Google Scholar
    • Export Citation
  • 42

    Yan SCHulsbergen AFCMuskens ISvan Dam MGormley WBBroekman MLD: Defensive medicine among neurosurgeons in the Netherlands: a national survey. Acta Neurochir (Wien) 159:234123502017

    • Search Google Scholar
    • Export Citation
  • 43

    Yu GJHan CZZhang MZhuang HTJiang YG: Prolonged drainage reduces the recurrence of chronic subdural hematoma. Br J Neurosurg 23:6066112009

    • Search Google Scholar
    • Export Citation
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