INTRODUCTION

 

Chronic subdural hematoma (CSDH) is a very common neurosurgical problem especially in elder age groups, yet there has been relatively little progress in its treatment.¹ A history of trauma head is usually there however many patients did not give a definite history. Other causes include post lumbar drainage², post ventriculoperiotneal shunts and even spontaneous in cases of idiopathic intracranial hypotension^.3,4

Although there are many trials for surgical techniques, neuroendoscopy, closed drainage system, still many different treatment options are adopted based on the center practice.

Theories of development of chronic subdural hematoma are controversial the origin of CSDH is usually a subdural hygroma (SDG), although a few cases are caused by acute subdural hematomas (ASDH). Subdural hygroma is produced by separation of the dura-arachnoid, interface, when there is sufficient subdural space. When the brain remains shrunken, the SDG remains unresolved.⁵

 

Any pathologic condition inducing cleavage of tissue within the dural border layer at the dura-arachnoid interface can induce proliferation of dural border cells with production of neo-membrane. In-growth of new vessels will follow, especially along the outer membrane, and then bleeding from these vessels occurs. These unresolved SDGs become CSDHs by repeated micro-hemorrhage from the neo-membrane.⁵

If the brain shrinks due to brain atrophy, excessive dehydration or decreased intracranial pressure and fluid collection may develop by a passive effusion⁶, which eventually increases the size of the hematoma and produce cerebral compression that leads to development of symptoms. Theoretically if this closed cavity of the duro-arachnoid interface is breached this will reverse the pathogenetic mechanism of development of hygromas and subsequently hematomas and prevent its recurrence.

 

Aim of Work

To assess the efficacy of breaching subarachnoid layer and creating a fistula to allow CSF flow into the subdural space to help rapid absorption of air and residual blood and prevention of late recurrence

 

MATERIALS AND METHODS

 

Thirty-seven patients admitted to Neurosurgery department; in Ain Shams University hospital in Egypt and Saudi German hospital in KSA, with chronic subdural hematoma surgically evacuated by burr-hole drainage included in this prospective study. A total of 31 males and 6 females patients (mean age 63 years, range 23 to 79). An average hospital stay days was 10, range 4 to 17 days. There was history of trauma in 23 cases, anticoagulant therapy in 7 cases for cardiac reasons, chronic liver disease in 4 cases, renal failure in 3 cases. Follow up period was for one year. I assessed the patients for recollection, air related complications and preoperative symptoms. All cases operated by single burr-hole technique under general anesthesia apart from seven high risk patients who were operated under local anesthesia.

After the regular evacuation of the hematoma, a needle tip or arachnoid knife is used to puncture the inner membrane of the cavity of the hematoma and arachnoid layer sharply and the hole is widened as possible. CSF will be seen flowing into the cavity. Occasional minor bleeding from underlying pia is simply controlled by small surgical piece and gentle pressure on small cottonoid. The residual cavity is filled with warm isotonic saline to help air to be pushed out. A subperiosteal suction drain is inserted. After drain fixation to scalp, a stay stitch is made around drain exit to be tightened after drain removal to prevent CSF leak from drain site, and the drain was left for 24 hours on mild suction then the suction is eliminated and is kept for passive drainage for another 24 hours. After follow up CT brain is satisfactory with no evidence of rebleeding or excessive air collection, the drain is removed.

 

Statistical Analysis

The statistical analysis of data done using excel program to express data in average, mean, and range.

 

RESULTS

 

There was no single active bleeding or recollection that necessitates re-evacuation during the follow up period. There were no air related complications like tension pneumocephalus. I had two cases (5.4%) of mortality within one week and after 6 months due hepatic encephalopathy. No wound related problems were encountered. CSF collection was seen in 10 cases (27%) and resolved spontaneously. There were three cases with CSF leak controlled by re-suturing of the drain exit site. Intraoperative excessive extradural bleeding in one case developed after the evacuation of hematoma and controlled by increasing the burr-hole size with extradural drain left.

All patients with neurologic deficits improved either during stay or on follow up visits. No worsening of preoperative symptoms. Patients with impaired conscious level had a longer hospital stay. Postoperative fits developed in three patients (8%), controlled by phenytoin therapy. There were no other related complications recorded other than for pre-existing medical condition. 

 

DISCUSSION

 

Chronic subdural hematoma (CSDH) is a common condition that increases in incidence with rising age.^{7, 8}

Although it is mostly affects elderly group of patients, yet it is seen in different age groups. Residual air, incomplete evacuation, rebleeding, recurrences and fits are common postoperative complications.^1,8 surgical management of CSDH is still a controversial issue, and a standard therapy has not been established because of the unclear pathogenic mechanisms in CSDH.⁹

Treatment options vary from conservative follow up, use of steroids to surgical evacuation. Surgical drainage of CSH may be as simple as bedside drill hole technique^1,10,11, burr hole evacuation⁹, up to craniotomy or up to endovascular embolization of middle meningeal artery in recurrent cases.¹²

Surgical treatment of CSDH is associated with good outcome in most of literatures. However the active rebleeding, recurrence and postoperative air are common problems together with postoperative fits, worsening of neurological status and infection .^9,13

Increased blood loss and extended hospital stay which increase the overall cost of the procedure. Although good effort to wash all residual blood and wash out any air, still some residual in the postoperative period exist and this prolongs the hospital stay and may increase morbidity or create mass effect.  In this work in 37 consecutive cases done with the new technique and there were good results as regard air collection and recurrence. The theory of the development of CSDH is based on the isolation of the collected blood from CSF and through creating a fistula that allows CSF to enter the subdural space will prevent the recurrence of hematoma in these patients also the continuous flow of CSF will help to wash out residual blood and helps rapid air absorption.

In this work CSF collection or leak encountered are considered good observation, yet was not clinically troublesome and were treated conservatively and spontaneously regressed. CSF leakage noticed in early cases prevented in later cases by suturing the drain exit. The presence of CSF leakage or collection is a good indicator of the concept of this work of effectiveness of fistula making delivering CSF into the subdural space which helps the internal wash of residual blood and air which is hypothesized to improve the postoperative course following drainage of chronic subdural hematoma and prevention of recurrence. Long terms follow up and bigger studies are important to support the data of this work.

 

Conclusion

Surgical drainage of CSDH with puncture of subarachnoid space to get free flow of CSF into the subdural space helps for internal wash of residual blood, rapid absorption of postoperative air and prevents short-term recollection. The technique is safe, easy and effective.

 

[Disclosure: Author reports no conflict of interest]

 

REFERENCES

 

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9.        Lin X. Comparing twist-drill drainage with burr hole drainage for chronic subdural hematoma. Chin J Traumatol. 2011; 14:170-3.

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12.     Hashimoto T, Ohashi T, Watanabe D, Koyama S, Namatame H, Izawa H, et al.  Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol Int. 2013; 4:104.

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