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Comparison of Outcome of Chronic Subdural Hematoma (SDH) in Terms of Recurrence with Drain and Without Drain

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Comparison of Outcome of Chronic Subdural Hematoma (SDH) in Terms of Recurrence with Drain and Without Drain PAKISTAN JOURNAL OF NEUROLOGICAL SURGERY (QUARTERLY) – OFFICIAL JOURNAL OF PAKISTAN SOCIETY OF NEUROSURGEONS Original Article Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence with Drain and without Drain Ehtisham Ahmed Khan Afridi1, Adil Ihsan1, Shabana Naz2, Gohar Ali3, Asghar Ali1, Shah Khalid1, Abdul Hameed Khan1, Mehboob Khan1 1Departments of Neurosurgery, Ayub Teaching Hospital, Abbottabad 2Department of Pathology, Ayub Teaching Hospital, Abbottabad 3Department of Neurosurgery, Bacha Khan Medical College, Mardan – Pakistan ABSTRACT Background/Objectives: Chronic subdural hematoma commonly reported in neurosurgical practices. Variations are reported in neurosurgical practices regarding the treatment of chronic subdural hematoma (SDH). This study determined the outcomes of SDH with Drain and without Drain in terms of recurrence and effectiveness. Material and Methods: A randomized control trial was conducted in the Department of Neurosurgery Ayub Teaching Hospital Abbottabad. Group-A patients were subjected to drainage of chronic subdural hematoma without drain and Group-B patients were subjected to drainage with drain. All patients were followed up to one month for recurrence of subdural hematoma like on CT-scan. Results: Overall, the recurrence of chronic subdural hematoma in both groups was seen in 16.7% of patients and the procedures were effective in 83.3% of patients. In Group A, 79.6% of patients were successfully treated through burr hole with irrigation, while 20.4% of patients had recurrent chronic SDH. In Group B, only 13% of patients had a recurrence, while 87% of patients were successfully treated with burr with the closed continuous drainage system. An insignificant difference (p-value: 0.302) existed between groups for both types of procedures. Conclusion: The patients who were treated with burr hole and irrigation of the subdural space with normal saline had high recurrence incidence than those with burr hole with closed continuous drainage system. Keywords: Chronic Subdural Hematoma (CSDH), Burr Hole with Irrigation, Burr Hole with Closed Drainage System, Recurrence. Corresponding Author: Ehtisham Ahmed Khan Afridi Date of Online Publishing: 13-06-2021 Department of Neurosurgery, ATH, Abbottabad Date of Print: 30-06-2021 E-mail: [email protected] DOI: 10.36552/pjns.v25i2.459 Date of Submission: 28-07-2020 Date of Revision: 22-04-2021 http//www.pakjns.org Pak. J. of Neurol. Surg. –2021 – 25 (2): 143-148. 143 Ehtisham Ahmed Khan Afridi, et al: Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence INTRODUCTION MATERIAL AND METHODS Chronic subdural hematoma is a collection of Study Design and Setting liquefied hematoma surrounding by capsule A randomized control trial was conducted at the within the subdural space,1 usually resulting from Department of Neurosurgery Ayub Teaching rupture of cortical veins, traumatic in nature and Hospital Abbottabad from October 2012 to most likely appear in patients with cerebral March 2013. Formal approval from the ethical atrophy, history of alcoholism or patients taking committee was obtained to conduct the study. anticoagulants, increased capillary fragility, abnormal gait, and patients with increase motor deficits. Other possible causes in the formation of Sample Size and Technique chronic subdural hematoma are arteriovenous A total of 54 patients were included in each group malformations, cerebral aneurysms, hemorrhagic using 9.3% the proportion of recurrence of 2,3 diathesis, brain tumors, and infectious diseases. subdural hematoma using drain and 24% Incidence of chronic subdural hematoma is 7.4 proportion of recurrence after not using any 2 out of 1000000 population, while another study drain.17 A 95% confidence interval and 90% power showed it to be 5 cases per 100 000 in the of the test were considered for the WHO sample 4 general population. size calculations. Consecutive non-probability In patients above 50 years of age, the brain sampling was considered. parenchyma becomes atrophic with reductions as low as 200 grams and consequently increased Inclusion Criteria dural space. Hemorrhage can easily occupy this space surrounding the brain without raising ICP All patients above the age of 20 years from both (intracranial pressure). The hematoma forms an sexes with chronic subdural hematoma on CT outer capsular layer. It absorbs subdural fluid, and scans, were included in the study. also develops vascular channels, that easily bleed. Because of loose cellular junctions. There is a Exclusion Criteria balance between the expansion of hematoma and Patients with any history of procedure for its absorption, and as this balance disrupts, the cerebrospinal fluid diversion, bleeding disorders, expanding hematoma produces symptoms. recurrence of subdural hematoma, chronic Patients with chronic subdural hematoma usually diseases of liver or kidneys or were on cardiac present with complaints of headache, weakness in medication or anticoagulants were not included one half of the body, unstable gait, balance loss, in the study to avoid bias. deteriorating memory, recurrent falls, confusion, lethargy, and dizziness.2 Chronic Subdural Hematoma commonly reported in neurosurgical Patient Groups practices. Variations are reported in neurosurgical Patients included admitted through OPD and practices regarding the treatment of chronic emergency. They were admitted to the subdural hematoma (SDH). This study aimed to neurosurgery department where written and evaluate the outcomes of SDH with drain and informed consents were taken. History and without drain in terms of recurrence and physical examination of each patient followed by effectiveness. neurological assessment were also carried out. Two groups were made where patients were randomly added by the lottery method. 144 Pak. J. of Neurol. Surg. – 2021 – 25 (2): 143-148. http//www.pakjns.org Ehtisham Ahmed Khan Afridi, et al: Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence Group A patients were subjected to drainage hematoma in both groups was seen in 18 (16.7%) of chronic subdural hematoma without drain. patients and the procedures were effective in 90 Group B patients were subjected to drainage (83.3%) patients and were not effective in 16.7% with drain. of patients. Tables 1 and 2 mention the detail. All patients were followed up to one month In Group A, 43 (79.6%) of patients were for recurrence of subdural hematoma on CT-Scan. successfully treated through burr hole with All the surgeries were performed by a single irrigation, while 11 (20.4%) of patients had experienced neurosurgeon. recurrent chronic SDH, so the procedure was effective in 79.6% of patients and was not Data Collection and Analysis effective in 20.4% of patients. Data collected for patients’ age, sex, type of procedure and recurrence, through a predesigned Table 1: Comparison of both groups in terms of proforma. All data entered, processed, and outcome and recurrence. analyzed with SPSS (version 24). Descriptive statistics were used to calculate the standard Recurrence of Subdural Hematoma Total deviation. Frequency and percentages were Yes No presented for gender and effectiveness. Chi- 11 43 54 square test was used for comparison in both Burr Hole with Irrigation 20.4% 79.6% 100.0% groups with a p-value of ≤ 0.05 as significant. Groups Burr Hole with 7 47 54 Closed Drainage 13.0% 87.0% 100.0% RESULTS System A total of 108 patients were studied, who met the 18 90 108 Total inclusion criteria like patients having age above 16.7% 83.3% 100.0% 20 years, patients of either gender and χ2 = 1.0677; p value = 0.302 Chi-Square &p-value symptomatic patients with a diagnosis of chronic (insignificant result) subdural hematoma on CT-Scan or MRI Brain. Table 2: Effectiveness of both Procedures. Gender Distribution Effectiveness Among these patients 104 (96.3%) were male and Yes No Total 4 (3.7%) were female patients. Burr Hole With 43 11 54 Irrigation 79.6% 20.4% 100.0% Age Range Groups Burr Hole With 47 7 54 Closed Drainage Age range was 23 years to 85 years with a mean 87.0% 13.0% 100.0% System age of 64.04 ± 10.29 years. 90 18 108 Total 83.3% 16.7% 100.0% χ2 = 1.0677; p value = 0.3017 Recurrence of Chronic Subdural Chi-Square & p-value Hematoma (insignificant result) Patients were randomly distributed into two groups, and each group includes 54 patients. As a In Group B, only 7 (13.0%) of patients had whole, the recurrence of chronic subdural recurrence, while 47 (87.0%) of patients were http//www.pakjns.org Pak. J. of Neurol. Surg. –2021 – 25 (2): 143-148. 145 Ehtisham Ahmed Khan Afridi, et al: Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence successfully treated with burr with a closed subdural hematoma. Stretch on the fragile continuous drainage system, so the procedure bridging veins in the atrophied brain gives way to was effective in 87.0% of patients and was not hematoma formation. Later followed by effective in only 13.0% of patients. An deposition of fibrin, organization of clot, insignificant difference (p-value: 0.302 > 0.05) fibrinolysis through enzymes, and then existed between groups for both types of liquification of the clot.9.10 In elderly patients, with procedures, that is, burr hole with irrigation and the atrophied brain, there is an 11% increase in burr hole with the closed drainage system. the extracerebral volume. The brain has more space for movement inside the skull and thus more chances of injuries to the bridging vessels. DISCUSSION Males have more exposure to injuries, hence the Variations are reported in neurosurgical practices higher percentage of males in both the studies. regarding the treatment of Chronic Subdural Recurrence of CSDH in our study was 16.7%, Hematoma (SDH). This study determined the which closely matches the results of the study outcomes of SDH with Drain and without Drain in done by Khan et al12 who showed in his study it terms of recurrence and effectiveness.
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