Drain Insertion in Chronic Subdural Hematoma: An International Survey of Practice

Objective

To investigate whether, after the publication of grade I evidence that it reduces recurrence rates, the practice of drain insertion after burr-hole drainage of chronic subdural hematoma has changed. Further, we aimed to document various practice modalities concerning the insertion of a drain adopted by neurosurgeons internationally.

Methods

We administered a survey to neurosurgeons worldwide with questions relating to the surgical treatment of chronic subdural hematoma, with an emphasis on their practices concerning the use of a drain.

Results

The preferred surgical technique was burr-hole drainage (89%). Most surgeons prefer to place a drain (80%), whereas in 56% of the cases the reason for not placing a drain was brain expansion after evacuation. Subdural drains are placed by 50% and subperiosteal drains by 27% of the responders, whereas 23% place primarily a subdural drain if possible and otherwise a subperiosteal drain. Three quarters of the responders leave the drain for 48 hours and give prophylactic antibiotic treatment, mostly a single-shot dose intraoperatively (70%). Routine postoperative computed tomography is done by 59% mostly within 24–48 hours after surgery (94%). Adjunct treatment to surgery rarely is used (4%).

Conclusions

The publication of grade I evidence in favor of drain use influenced positively this practice worldwide. Some surgeons are still reluctant to insert a drain, especially when the subdural space is narrow after drainage of the hematoma. The insertion of a subperiosteal drain could be a good alternative solution. However, its outcome and efficacy must be evaluated in larger studies.

Introduction

The incidence of chronic subdural hematoma (cSDH) is estimated at 1.7–18 per 100,000 people, increasing to 58 per 100,000 in patients older than the age of 65 years, making it one of the most common neurosurgical conditions.1, 2 Most physicians would agree that surgical evacuation of the hematoma is the preferred treatment for symptomatic patients.³ In small hematomas or asymptomatic patients, several medical agents have been investigated; however, there remains a lack of evidence concerning their efficiency.⁴ Surgical treatment via burr-hole drainage (BHD) is well established2, 3, 5; however, recent studies show comparable outcomes for twist drill craniostomy (TDC).⁶

Despite its high incidence, high-class evidence for the management of cSDH is limited. The only well-designed randomized trial on cSDH showed that a subdural drain reduces the rate of recurrence and improves functional outcome.⁷ Recommendations on the amount of burr holes that should be undertaken, where the drain should be placed (e.g., subdural or subperiosteal), the duration of drain placement, application of perioperative antibiotics, and performing postoperative imaging are based mostly on case series, hence on low-grade evidence.³ Because of the lack of evidence, a vast variety of treatment modalities exist when neurosurgeons treat cSDH. The aim of this international survey was to investigate whether practice concerning drain insertion after burr hole drainage of cSDH after the publication of Santarius et al.⁷ has changed. Furthermore, we aimed to document various practice modalities concerning the insertion of a drain adopted by neurosurgeons internationally.