Management of chronic subdural haematoma

Thomas Santarius and colleagues1Santarius T Kirkpatrick PJ Ganesan D et al.Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial.Lancet. 2009; 374: 1067-1073Summary Full Text Full Text PDF PubMed Scopus (388) Google Scholar show, in a randomised controlled trial, the effect of drains after burr-hole evacuation of chronic subdural haematoma on recurrence rates and clinical outcomes. We believe that some concerns should be addressed to avoid weakening the strength of this message.First, Santarius and colleagues conclude that surgical complications were not more common in those with drains than in those without. However, there are no data to prove this in their paper. Although the prognosis is generally good and treatment modalities are well established, unexpected neurological deterioration may complicate burr-hole evacuation and continuous closed-system drainage. Seizures, intracerebral haemorrhage, and subdural empyema are well known complications after surgical evacuation of chronic subdural haematomas.2Rohde V Graf G Hassler W Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: a retrospective analysis of 376 patients.Neurosurg Rev. 2002; 25: 89-94Crossref PubMed Scopus (118) Google Scholar Tension pneumocephalus,3Sharma BS Tewari MK Khosla VK Pathak A Kak VK Tension pneumocephalus following evacuation of chronic subdural haematoma.Br J Neurosurg. 1989; 3: 381-387Crossref PubMed Scopus (23) Google Scholar intracerebral haematoma, and acute epidural haematoma have also been reported after the surgical evacuation of chronic subdural haematomas. Since Santarius and colleagues did not compare the rate of medical or surgical complications between drain and no drain groups, their conclusion should be interpreted with some caution.Second, using data shown in table 4, Santarius and colleagues suggest that only the presence of coagulopathy, platelet dysfunction, scores on the Glasgow coma scale and modified Rankin scale, and neurological deficit had a significant association with recurrence. However, as we know, the routine use of steroids has the potential to decrease the rate of recurrence.4Sun TF Boet R Poon WS Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone.Br J Neurosurg. 2005; 19: 327-333Crossref PubMed Scopus (112) Google Scholar We therefore suggest that the routine use of steroids needs logistic regression analysis.We declare that we have no conflicts of interest. Thomas Santarius and colleagues1Santarius T Kirkpatrick PJ Ganesan D et al.Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial.Lancet. 2009; 374: 1067-1073Summary Full Text Full Text PDF PubMed Scopus (388) Google Scholar show, in a randomised controlled trial, the effect of drains after burr-hole evacuation of chronic subdural haematoma on recurrence rates and clinical outcomes. We believe that some concerns should be addressed to avoid weakening the strength of this message. First, Santarius and colleagues conclude that surgical complications were not more common in those with drains than in those without. However, there are no data to prove this in their paper. Although the prognosis is generally good and treatment modalities are well established, unexpected neurological deterioration may complicate burr-hole evacuation and continuous closed-system drainage. Seizures, intracerebral haemorrhage, and subdural empyema are well known complications after surgical evacuation of chronic subdural haematomas.2Rohde V Graf G Hassler W Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: a retrospective analysis of 376 patients.Neurosurg Rev. 2002; 25: 89-94Crossref PubMed Scopus (118) Google Scholar Tension pneumocephalus,3Sharma BS Tewari MK Khosla VK Pathak A Kak VK Tension pneumocephalus following evacuation of chronic subdural haematoma.Br J Neurosurg. 1989; 3: 381-387Crossref PubMed Scopus (23) Google Scholar intracerebral haematoma, and acute epidural haematoma have also been reported after the surgical evacuation of chronic subdural haematomas. Since Santarius and colleagues did not compare the rate of medical or surgical complications between drain and no drain groups, their conclusion should be interpreted with some caution. Second, using data shown in table 4, Santarius and colleagues suggest that only the presence of coagulopathy, platelet dysfunction, scores on the Glasgow coma scale and modified Rankin scale, and neurological deficit had a significant association with recurrence. However, as we know, the routine use of steroids has the potential to decrease the rate of recurrence.4Sun TF Boet R Poon WS Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone.Br J Neurosurg. 2005; 19: 327-333Crossref PubMed Scopus (112) Google Scholar We therefore suggest that the routine use of steroids needs logistic regression analysis. We declare that we have no conflicts of interest. Management of chronic subdural haematoma – Authors' replyVafa Rahimi-Movaghar and colleagues query the cause of death at 6 months. Mortality was a secondary endpoint in our study, but there were nine deaths at 6 months in the drain group and 19 in the non-drain group (p=0·042). Unfortunately, autopsies are not routinely done in the UK. However, a systematic review of causes of death in chronic subdural haematoma is underway. Full-Text PDF