Efficacy of Single Burr Hole in Management of Chronic Subdural Hematoma

Background: Surgery of chronic subdural hematoma (CSDH) is a common practice of neurosurgeons. CSDH is considered a pathology of the elderly and usually many co-morbidities are present. CSDH carries high risk of mortality if not treated or not treated well. So, the minimal, safe and adequate surgical intervention is the bases to choose specific surgical maneuver. Aim of the Study: The efficacy of a single burr in evacuation and treatment of chronic subdural hematoma. Methods: This study was held in Assiut university hospitals, neurosurgical department. It is a prospective randomized controlled study. 113 patients were enrolled in this study in the period between March 2018 and June 2019. We included all cases of chronic subdural hematoma (CSDH) and subacute subdural hematoma that were evacuated with single burr hole. Hematomas either, unilateral or bilateral were included. Septated hematomas were excluded. Patients’ clinical characteristics as age, sex, clinical presentation, co-morbidities and patients outcome were recorded. Postoperative status as regards improvement of the neurological status, complications and recurrence of hematoma were recorded. Results: We had 113 patients operated via properly situated single burr hole in our study. 113 patients were included in this study, 79 males (69.9%) and 34 females (30.1%). Age of the patients ranges between 27 years old and 90 years old. Postoperative follow up was evaluated according to Glasgow outcome score (GOS). We had 98 patients with good recovery, 4 patients with moderate disability, 6 patients with severe disability and 5 patients died. Complications were in form of 3 patients with residual hematoma, 2 patients with tension pneumocephalus, 7 patients developed postoperative seizure, 5 cases developed cortical/parenchymal hematoma and 9 cases developed hematoma recurrence. Conclusion: Single, properly situated burr hole with previously described characters is an effective treatment option in cases of CSDH. It helps adequate, effective and safe removal of the pathology with limited maneuver. How to cite this paper: Elshanawany, A.M., Abokresha, A.E. and Mahmoud, M. (2020) Efficacy of Single Burr Hole in Management of Chronic Subdural Hematoma. Open Journal of Modern Neurosurgery, 10, 81-87. https://doi.org/10.4236/ojmn.2020.101009 Received: October 19, 2019 Accepted: December 2, 2019 Published: December 5, 2019 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access A. M. Elshanawany et al. DOI: 10.4236/ojmn.2020.101009 82 Open Journal of Modern Neurosurgery


Background
Chronic subdural hematoma (CSDH) is defined as the presence of liquefied blood within a membrane in the cavity after 3 weeks or more of acute bleeding in the subdural space [1]. Its pathogenesis is a progressive process and if not treated, it may carry a great risk for severe morbidity and mortality [2]. Standard treatment of CSDH is surgical evacuation [3]. CSDH is considered a disease of the elderly and most patients have many comorbidities such as cardiac diseases, chronic antiplatelet therapy, hepatic and etc. These co-morbidities affect the prognosis and feasibility of surgical intervention [3]. The best surgical procedure for treatment of chronic subdural hematoma is that allow adequate drainage with short operative period and least invasive. The aim of this work is to evaluate the efficacy of a single burr in evacuation and treatment of chronic subdural hematoma.

Methods
This study was held in Assiut university hospitals, neurosurgical department. It is a prospective randomized controlled study. 113 patients were enrolled in this study in the period between March 2018 and June 2019. Those patients who were admitted in our department during the previous period in our department.
We included all cases of chronic subdural hematoma (CSDH) that need surgical evacuation. Subacute subdural hematoma was included as they need the same treatment option. Hematomas either, unilateral or bilateral were included. Septated hematomas were excluded. Patients' clinical characteristics as age, sex, clinical presentation, co-morbidities and patients outcome were recorded.
Hematoma evacuation was performed through single burr hole. The burr hole was situated over the maximum thickness of hematoma. In cases when the hematoma thickness almost equal, burr hole is situated at the junction between anterior two thirds and posterior one third of the hematoma. Burr hole diameter is adjusted to be 20 mm. To ensure adequate drainage and avoid air collection in subdural space, head position is designed to make burr hole in the uppermost point as much as we can. Subcutaneous drain around burr hole edge is left for 24 or 48 hours till stoppage of fluid drainage.
Postoperative status as regards improvement of the neurological status, residual hematoma and recurrence of hematoma were recorded. We defined patients with residual hematoma as that did not improve postoperatively and follow up CT revealed significant subdural collection with mass effect. We defined patients with hematoma recurrence as those developed reappearances of symptoms or re-accumulation of hematoma. Recorded clinical conditions on admission and on discharge were evaluated according to neurological grading system  Table 1) [4]. Average postoperative follow up periods range were three months.

Results
113 patients were included in this study, 79 Males (69.9%) and 34 females (30.1%). Age of the patients ranges between 27 years old and 90 years old ( Table   2). The mean age was 69.37. There were 63 patients were presented with disturbed conscious level. 39 patients were presented with right sided hemiparesis. Left hemiparesis was seen in 48 patients. Quadriparesis was seen in 19 patients. We observed manifestations of increased intracranial tension in 7 patients (Table 3).    Table 5. We had 5 patients who died within the first week after surgery because of co-morbidities.

Discussion
Surgery of chronic subdural hematoma (CSDH) is a common practice of neurosurgeons. CSDH is considered a pathology of elderly and usually many co-morbidities are present. CSDH carries high risk of mortality if not treated or not treated well. Burr hole evacuation is considered the treatment of choice of CSDH [5] [6].
Evacuation of the hematoma through one burr hole is considered less minimal than evacuation through two burr holes. Also, it is better than using twist drill as it has better exposure and adequate hemostasis with the same minimal proce-  [20]. Chih-Wei, C. et al., reported an incidence of 5.4% of postoperative seizure in their study [21]. In our series 5 patients had cortical and parenchymal hematomas. In the literature parenchymal hemorrhage is rare devastating complication that usually occurs in those with coagulopathy [22]. In our series only two of the five that developed post evacuation hemorrhage were with coagulopathy. The other 3 patients were with normal coagulation profile. The occurrence of hematomas in those patients could be explained on bases of forceful irrigation and rapid decompression of the brain after hematoma evacuation. To avoid occurrence of this serious com-

Conclusion
Single, properly situated burr hole with previously described characters is an effective treatment option in cases of CSDH. It helps adequate, effective and safe removal of the pathology with limited maneuver.

Ethical Clearance
This work fulfills all the ethical requirements and criteria.