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      A New Modified Twist Drill Craniostomy Using a Novel Device to Evacuate Chronic Subdural Hematoma

      research-article
      Author(s): , MD, , MD, , MD, PhD
      Editor(s):
      Publication date (Electronic):
      Journal: Medicine
      Publisher: Wolters Kluwer Health

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          Abstract

          Compared with burr hole craniostomy (BHC), twist drill craniostomy (TDC) is increasingly popular because of its minimal invasiveness in evacuating chronic subdural hematoma (CSDH). However, the TDC technique varies and is continually developing; moreover, no consensus yet exists regarding the optimal protocol, and the efficacy and safety of TDC is still controversial, especially with respect to a specific method. This article introduces a new modified TDC technique using a novel device, the YL-1 puncture needle, and evaluates its efficacy and advantages compared with BHC.

          A retrospective study involving 121 patients with CSDH who underwent surgery at a single center was conducted, involving 68 patients undergoing modified TDC (TDC group) and 53 patients treated by BHC (BHC group). The neurological outcome was studied to evaluate the surgery efficacy, and the radiological outcome was assessed as a supplement to the surgery efficacy. In addition, complications, recurrence, and reoperation, as well as pneumocrania, operation duration, and length of stay, were studied to evaluate the advantages of the modified TDC compared with BHC. Independent sample t tests or rank-sum tests were used to compare the outcomes between the 2 groups.

          The neurological and radiological outcomes did not differ significantly between the TDC and BHC groups ( P = 0.852 and P = 0.232, respectively), while the rates of complication and pneumocrania in patients who underwent the modified TDC were significantly lower than that in those who underwent BHC ( P = 0.021 and P < 0.001, respectively). The recurrence and reoperation rates in patients from the 2 groups were similar ( P = 0.566 and P = 0.715, respectively). The operation duration and length of hospital stay of the patients who underwent the modified TDC were significantly shorter than those of the patients who underwent BHC (both P < 0.001).

          Modified TDC with a YL-1 puncture needle is a minimally invasive surgical technique to treat CSDH; this procedure is as effective as BHC, but safer and simpler than BHC, and should be considered for patients with CSDH, especially the elderly.

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          The surgical management of chronic subdural hematoma.

          Eric Sussman, Kristen Anderson, E Connolly … (2012)
          Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.
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            The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage.

            M Rohner, T Markwalder, K Steinsiepe … (1981)
            A consecutive series of 32 adult patients with chronic subdural hematoma was studied in respect to postoperative cerebral reexpansion (reduction in diameter of the subdural space) after burr-hole craniostomy and closed-system drainage. Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. Our study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly.
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              Choosing the best operation for chronic subdural hematoma: a decision analysis.

              Gary Stein, N. Malhotra, Shabbar Danish … (2010)
              Chronic subdural hematoma (CSDH), a condition much more common in the elderly, presents an increasing challenge as the population ages. Treatment strategies for CSDH include bur-hole craniostomy (BHC), twist-drill craniostomy (TDC), and craniotomy. Decision analysis was used to organize existing data and develop recommendations for effective treatment. A Medline search was used to identify articles about treatment of CSDH. Direct assessment by health care professionals of the relative health impact of common complications and recurrences was used to generate utility values for treatment outcomes. Monte Carlo simulation and sensitivity analyses allowed comparisons across treatment strategies. A second simulation examined whether intraoperative irrigation or postoperative drainage affect the outcomes following BHC. On a scale from 0 to 1, the utility of BHC was found to be 0.9608, compared with 0.9202 for TDC (p = 0.001) and 0.9169 for craniotomy (p = 0.006). Sensitivity analysis confirmed the robustness of these values. Craniotomy yielded fewer recurrences, but more frequent and more serious complications than did BHC. There were no significant differences for BHC with or without irrigation or postoperative drainage. Bur-hole craniostomy is the most efficient choice for surgical drainage of uncomplicated CSDH. Bur-hole craniostomy balances a low recurrence rate with a low incidence of highly morbid complications. Decision analysis provides statistical and empirical guidance in the absence of well-controlled large trials and despite a confusing range of previously reported morbidity and recurrence.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Medicine (Baltimore)
                Journal ID (iso-abbrev): Medicine (Baltimore)
                Journal ID (publisher-id): MEDI
                Title: Medicine
                Publisher: Wolters Kluwer Health
                ISSN (Print): 0025-7974
                ISSN (Electronic): 1536-5964
                Publication date Collection: March 2016
                Publication date (Electronic): 11 March 2016
                Volume: 95
                Issue: 10
                Electronic Location Identifier: e3036
                Affiliations
                From the Department of Neurosurgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu (Q-FW); Department of Neurosurgery, The Second Clinical School, Yangzhou University, Yangzhou (CC); and Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu (CY), China.
                Author notes
                Correspondence: Chao You, Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China (e-mail: youchaoscuwch@ 123456163.com ).
                Article
                Accession ID: 03036
                DOI: 10.1097/MD.0000000000003036
                PMC ID: 4998904
                PubMed ID: 26962823
                SO-VID: 15f94346-34c7-45b2-8ea2-bd4ad94c49f3
                Copyright © Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
                License:

                This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

                History
                Date received : 29 November 2015
                Date revision received : 28 January 2016
                Date accepted : 10 February 2016
                Categories
                Subject: 7100
                Subject: Research Article
                Subject: Observational Study
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