Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases

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Object. Subduroperitoneal drainage (SDPD) is commonly used in the treatment of infantile subdural hematomas (SDHs). Few studies have focused on this technique and most series have included SDHs of various origins in children of different ages. The surgical procedure is not standardized and results achieved using this technique have not been well documented.

The authors reviewed their cases of traumatic SDH treated with SDPD in infants (< 2 years of age). Their standard technique includes bilateral SDPD whenever the SDH is bilateral, placement of a free shunt, and systematic removal of the drainage unit after a few months.

Methods. The authors performed SDPD in 244 infants with traumatic SDH. The patients' SDHs were controlled by SDPD in 241 cases, and 78.9% of the patients recovered to live a normal life. Complications of SDPD occurred in 38 patients (15.6%): obstruction in 22 cases (9%), infection in eight cases (3.28%), and internal hydrocephalus in eight cases (3.28%). Early complications could be ascribed to surgical technique, delayed complications were associated with the severity of the initial clinical presentation, and late complications were time dependent and unrelated to initial clinical severity. Poor clinical outcome was correlated to the severity of the initial presentation, but not to complications of surgery.

Conclusions. Because of its efficacy and low complication rate, SDPD is the procedure of choice when subdural taps fail to control SDH. The authors prefer bilateral drainage because of the low rate of complications. Drains should be systematically removed after a few months to prevent long-term complications.

Article Information

Address reprint requests to: Matthieu Vinchon, M.D., Department of Pediatric Neurosurgery, Centre Hospitalier Regional Universitaire de Lille, 59 037 Lille Cedex, France. email: m-vinchon@chru-lille.fr.

© AANS, except where prohibited by US copyright law.

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Figures

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    Bar graph showing the age distribution of patients at the time of surgery. Subdural hematomas are almost specific to infants younger than 1 year of age. The sharp decline in incidence as patients age coincides with the acquisition of sitting and standing postures, suggesting an earlier period of increased vulnerability.

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    Neuroimaging obtained in a 2-month-old male infant with a large head at birth (head circumference 40 cm), who presented with signs of raised intracranial pressure without any history of trauma. Left: Initial axial CT scan revealing the association of SDH and expanded sulci. Intracranial hypertension was not relieved by subdural taps and the patient underwent insertion of a SDPD unit 6 days after admission, resulting in complete resolution of symptoms. Center: Postoperative frontal T2-weighted MR image obtained 2 months later, demonstrating partial collapse of the SDH and healing of the outer layer of the arachnoid around the catheters (arrowheads). Right: Axial CT scan obtained 6 months after drainage, but before shunt removal, confirming complete resolution of the subdural collection.

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    Postoperative frontal T1-weighted MR image obtained 12 days after shunt insertion in a 2-month-old male infant with shaken-baby syndrome who presented with seizures and raised intracranial pressure. The subdural collection is clearly delineated from the subarachnoid space, and the protein content is distinctly different on both sides. One day after the MR image was obtained, the infant underwent a second surgery because the peritoneal end of the shunt was obstructed. His postoperative course was uneventful.

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    Kaplan—Meier survival curve showing the overall incidence of SDPD complications related to postoperative time. Triangles indicate patients in whom the shunt was removed systematically or who were without complication at the last control examination. Most SDPD units were removed within 6 months after insertion. For the remaining shunts, complication-free survival stabilized after 3 years at 55.3%, and the estimated annual incidence of complications was 17.9% during the first 3 postoperative years.

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    Kaplan—Meier complication-free survival curves for patients with SDPD, stratified according to their initial clinical status (severe = deficit, coma, or status epilepticus). The complication-free survival time was significantly lower for patients with severe clinical status at the time of surgery, although the final complication rate was similar in both groups. This suggests that complications can be separated into two groups: early complications, which are associated with clinical severity, and late time-dependent complications.

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