Elsevier

World Neurosurgery

Volume 100, April 2017, Pages 480-486
World Neurosurgery

Original Article
Twist Drill Procedure for Chronic Subdural Hematoma Evacuation: An Analysis of Predictors for Treatment Success

https://doi.org/10.1016/j.wneu.2017.01.037Get rights and content

Background

Twist drill craniostomy (TDC) is a minimally invasive and cost-effective technique to treat chronic subdural hematomas (CSDHs). Predictors for treatment success such as imaging characteristics, hematoma volume, and drainage volume are not established; thus, they are purpose of this analysis.

Material and Methods

We retrospectively evaluated all data of patients with CSDH undergoing TDC in our institution between January 2010 and December 2013. We analyzed imaging characteristics (extension and composition), volumetrically calculated pre- and postoperative hematoma volumes, measured drainage volume, and clinical course. Primary treatment success was defined as sufficient if definitive treatment was achieved via a single TDC (TDC-1) and insufficient if more than one TDC was needed. The need for open surgical evacuation was defined as treatment failure.

Results

Data of 233 patients undergoing 387 TDCs were available for our study. A total of 67% of TDCs treated CSDHs effectively, whereas the remainder required further open surgical evacuation. Via use of the median-split-method, we found that sufficient treatment was achieved more frequently in smaller hematomas (P < 0.05). Treatment effectiveness was neither correlated with hematoma image characteristics (presence of membranes: P = 0.11, extent of chronification: P = 0.55) nor with the respective drainage volume (P = 0.95). Residual hematoma volume was consistently greater than expected by drainage calculation (P < 0.05).

Conclusions

TDC is an effective treatment option for CSDH. Sufficient treatment with single TDC was more common in smaller hematomas with an associated smaller residual hematoma. Failure of brain re-expansion after TDC may increase the treatment failure rates. In these cases, an open surgical evacuation might accelerate treatment and clinical recovery.

Introduction

Chronic subdural hematoma (CSDH) is one of the most frequent neurosurgical afflictions encountered in daily clinical practice.1 The incidence of CDSH is estimated to be 1.72 in 100,000 per year in northern Europe, with a clearly increased rate up to 7.4 in 100,000 per year among the elderly population.1, 2 The vast majority of the neurosurgical literature concerning this disease discusses various surgical techniques for first-line treatment.3 Historically, the treatment of choice has been open evacuation via craniotomy or burr hole(s) with or without irrigation.4, 5, 6 Because of the aging of our society, the increasing rate of comorbidities, and frequent use of anticoagulant agents among elderly patients, invasive evacuation techniques of CDSH have been supplanted by less-invasive ones, such as drainage via single small burr hole or twist drill craniostomy (TDC).3, 6

It generally is recognized that TDC is a minimally invasive, safe, and fast treatment option for CSDHs, particularly in elderly patients.6, 7 The technique, effectiveness, and safety of TDC have been evaluated previously in various studies.5, 6, 8, 9, 10, 11 Nevertheless, particular specifications for predictive factors that could influence the treatment result of CSDH via TDC are still lacking. The purpose of our present study was first to evaluate the influence of the preoperative hematoma volume, presence of membranes, and the extent of chronification on the treatment effectiveness of TDC, and second to determine possible predictive factors for sufficient treatment with this technique to accelerate treatment process and clinical recovery.

Section snippets

Patients

The study was a retrospective review of all hospital and clinic records of patients with CSDH treated via a TDC between January 2010 and December 2013 at our institution. Clinical and imaging data were analyzed via a query of a prospectively maintained database of all adult inpatients admissions to the neurosurgical department of the university hospital with the ICD I62.02. Space-occupying hematomas as well as hematomas with refractory headache and/or neurologic deficits were defined as

Results

For our analysis, comprehensive data sets of 233 patients (female = 82, male = 151; mean age 75.2 ± 12.9 years) were available with a total of 253 symptomatic CSDHs (unilateral: n = 161; bilateral: n = 72), undergoing a total 387 TDC procedures. The most common presenting symptoms were refractory headache (28%), paresis (22%), and drowsiness or decreased consciousness (19%) (Table 1).

Overall, 260 (67%) primary or secondary TDCs effectively treated CSDHs in 133 (57%) patients without the need of

Discussion

Age, Glasgow Coma Scale score at presentation, and comorbidities such as cardiac and renal disease are considered to be the most important factors for the treatment strategy and patient's outcome in CSDH.12 The most common surgical approaches reported in the literature are craniotomy, burr hole craniostomy, and twist drill, in combination with variable supplementary techniques of irrigation and drainage.4, 7, 13, 14, 15

Presently available data, however, do not provide a specific recommendation

Conclusions

TDC is an effective, minimally invasive method to treat CSDH with an acceptable success rate. The effectiveness of treatment did not depend on hematoma composition. Treatment failure is more likely in large hematomas, with an associated large residual hematoma. Failure of brain re-expansion after hematoma drainage may account for greater recurrence or treatment failure rates. In these patients, an open surgical evacuation might accelerate the treatment and clinical recovery.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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