Recurrent Chronic Subdural Hematoma After Burr-Hole Surgery and Postoperative Drainage

Operative Neurosurgery 25:216–241, 2023

Reported recurrence rates of chronic subdural hematoma treated by burr-hole surgery with postoperative drainage vary considerably in the literature. We performed a systematic review and meta-analysis to define the recurrence rate of burr-hole surgery with postoperative drainage.

METHODS: PubMed and EMBASE were searched, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. We used the Newcastle-Ottawa scale and Cochrane risk-of-bias tool for quality assessment of included studies and the random-effects model to calculate pooled incidence rates in R with the metaprop function if appropriate.

RESULTS: The search yielded 2969 references; 709 were screened full text, and 189 met the inclusion criteria. In 174 studies (34 393 patients), the number of recurrences was reported as per patient and 15 studies (3078 hematomas) reported the number of recurrences per hematoma, for a pooled incidence of 11.2% (95% CI: 10.3-12.1; I 2 = 87.7%) and 11.0% (95% CI: 8.6-13.4; I 2 = 78.0%), respectively. The pooled incidence of 48 studies (15298 patients) with the highest quality was 12.8% (95% CI 11.4-14.2; I 2 = 86.1%). Treatment-related mortality (56 patients) has a pooled incidence of 0.7% (95% CI 0.0-1.4; I 2 = 0.0%).

CONCLUSION: The recurrence rate of chronic subdural hematoma treated by burr-hole surgery and postoperative drainage is 12.8%.


Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

Neurosurgery 91:842–855, 2022

Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment.

OBJECTIVE: To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH.

METHODS: A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component.

RESULTS: In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36- 0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments.

CONCLUSION: Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.


Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis

Acta Neurochirurgica (2020) 162:499–507

Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking.

Methods We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications.

Results Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + −19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%–31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%–27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%–6%, I2 = 0) compared to conventional groups.

Conclusions Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Subdural motor cortex stimulation

Subdural motor cortex stimulation

Acta Neurochir (2014) 156:2289–2294

Motor cortex stimulation (MCS) is considered to be an effective treatment in some types of chronic refractory neuropathic pain. The aim of this study is to evaluate and confirm the feasibility, efficacy and security of our surgical technique for subdural motor cortex stimulation (SDMCS) on 18 consecutive cases with follow-up of at least 3 years.

Methods Our population consists of 18 consecutive patients (12male) between 2000 and 2010,with a mean age of 63 years (11–91). The mean follow-up was 86 months (20–140 months). We identified the central sulcus by using classical anatomic landmarks and neuronavigation (BrainLab system; BrainLAB, Inc., Redwood City, CA). An elongated craniotomy (3 cm in length, 1 cm in width)was performed followed by linear opening of the dura mater. An eight-polar plate electrode (Specify Lead, 3998;Medtronic,Minneapolis,MN) was then slipped smoothly through this linear opening. In patients with interhemispheric electrodes (patients 2 and 17), we performed a parasagittal craniotomy of 4 cm length and 2 cm width.

Results At last follow-up assessment, 14 patients had a favourable outcome (77.7 %): 10 patients with excellent relief of pain (>80 %), 1 with good relief of pain (60–80 %) and 3 with satisfactory relief of pain (50–60 %). Four patients showed bad results (<50 %). We did not observe any late complications specific to SD MCS.

Conclusion We report an efficacy at least as good as ED MCS, with no complications specific to SD MCS, even with prolonged follow-up. The data are insufficient to actually prove a lower energy use in SD MCS.

Keywords Neuropathic pain , Neurostimulation , Motor cortex stimulation, Subdural