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CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION

CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION. INTRODUCTION. 1)chronic subdural haematoma(CSDH) is common intracranial pathology in elderly people. 2)recurrence rate ranges 9.2-26.5% after surgical interventions.

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CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION

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  1. CHRONIC SUBDURAL HEMATOMA-CRANIOTOMY VS BURR HOLE TREPANATION

  2. INTRODUCTION • 1)chronic subdural haematoma(CSDH) is common intracranial pathology in elderly people. • 2)recurrence rate ranges 9.2-26.5% after surgical interventions. • 3)incidence of CSDH likely to rise due to increase life expectancy &more number of people receiving anticoagulant ,antiplatelet agents.

  3. Craniocerebral injuries from acute subdural haematoma &subdural hygroma results in formation of chronic subdural haematoma.

  4. MECHANISM: • Neomembrane produced by dural border cells in unresolved hygroma results in vascularization with fragile blood vessels and repeated bleedings. • Failure of resorption of coagulated blood with subsequent granulation tissue and angiogenesis with fragile blood vessels in setting of ASDH.

  5. TREAT MENT OPTIONS • 1)Burr hole craniotomy • 2)trepanation &twist drill craniotomy with or without irrigation/with or without drainage.

  6. Ususal presentation of chronic subdural haematoma: 1)Headache 2)Decrease conciousness 3)Aphasia 4)Behavioral disturbances 5)Paresis 6)Seizure

  7. During 5 yrs study at neurosurgery department at Hannover (between march 2003-july 2008): • Pre and post operative CT images taken. • Pre-operative clinical appearance &post –operative clinical outcome.

  8. RISK FACTORS: • Anticoagulant therapy • Antiplatelet agents • Coagulopathy • Alcohol abuse

  9. Out of 193 patients: • 151 patients had osteoplastic craniotomy with subdural drainage and low suction vacuum reservior. • 42 patients had burr hole trepanation with subdural drainage and low suction vacuum reservior.

  10. Careful irrigation with ringer lactate followed in every operation untill the irrigation solution remained clear. • All the drains were removed within 3 days.

  11. Patient’s mean age 72.5 yrs • Males:113(59%) • Females:80(41%) • Chronic subdural hematoma location: • 90 cases(47%) in left hemisphere. • 74 cases(38%)in right hemisphere. • 29 cases(15%)in both hemisphere.

  12. 40%patients were receiving antiplatelet and anticoagulant therapy. • Coagulopathy obsereved in 2% patients. • Alcohol abuse present in 6% of patients.

  13. Most frequent clinical signs were: Hemiparesis:112(58%) Decrease conciousness:70(36.3%) Aphasia:46(23.8%) All the patients with above clinical signs showed chronic subdural hematoma in CThead.

  14. CRANIOTOMY GROUP Complete clinical recovery 68.9%(104) No change in clinical condtion or worsening 31.1%(47) BURR HOLE GROUP Complete clinical recovery85.7%(36) No change in clinical condtion or worsening 14.3%(06) Post-operative clinical improvement

  15. Recurrence rate was 27.8%(42 cases) in patients treated with craniotomy &drainage • And 14.3%(06 cases) in patients treated with burr hole drainage. • Seizures were observed in 15 patients (6.7%) pre-operatively &in 14 patients (7.3%) post-operatively.

  16. 137 patients(70%)or their relatives documented history of head trauma. • Mean interval for development of CSDH is 37.3 days(range 1-230 days.)

  17. RECOVERY AND DISCHARGE INDICES • 79 cases(52.3%)with craniotomy and sub dural drainage & 27 cases(64.3%)with burr hole and sub dural drainage were discharged home for self care.

  18. 16 cases(8.6%)discharged to another specialist department for treatment of accompyning disease. • 8 cases(5.3%) in craniotomy group and 3 cases(7.2%) in burr hole group were sent to nursing home. 7 cases(4.6%)of craniotomy group and 1 case(2.4%) of burr hole group died in hospital stay because of internal disease not directly attributable to CSDH.

  19. Incidence of pre-op seizures was 6.7% • Post-op seizures incidence:7.3% • Chen-et-al correlated increase incidence of post-op seizures in patient with left unilateral CSDH and CT appearance of mixed density type lesion.

  20. Santarious-et-al randomised 215 patients with CSDH with drain and without drain. • Use of drain with burr hole irrigation is associated with lower recurrence rate,,better neurological status at discharge and lower mortality at 6 months.

  21. Zakaria-et-al compared 42 patients treated with burr hole craniotomy(with drainage) without irrigation and 40 patientswith irrigation and drainage. • No significant difference in outcome between both groups was observed. • A recurrence rate was same (12.2%)

  22. Okado-et-al compared 20 patients treated by burr hole irrigation with 20 patients treated by burr hole drianage. • Hospitalization (post-op)stay was 14.1 in drainage group. • Hospitalization (post-op) stay was 25.5 in irrigation group.

  23. CONCLUSION • Single institution 5 yrs retrospective study of 193 patients was done with consideration of clinical presentation,surgical technique and outcome of CSDH. • History of trauma recognised in 71% with mean interval of time gap of 37 days.

  24. Antiplatelet and anticoagulant therapy was present in 40% of patients. • Most frequent pre-operative symptom was hemiparesis(58%) • 75% of patient had surgery succesfully performed.

  25. 25% received revision surgery with 3 cases(1.6%)undergoing craniectomy as second revision. • CSDH is a common disease very frequent in elderly population predominantly affecting male patients. • Burr hole trepanation evacuation seems to lead to superior results.

  26. Osteoclastic craniectomy might represent surgical option in complicated recurrent cases.

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