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.

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

5. 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.

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

7.  Ususal presentation of chronic subdural haematoma: 1)Headache 2)Decrease conciousness 3)Aphasia 4)Behavioral disturbances 5)Paresis6)Seizure

8.  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.

9. RISK FACTORS:  Anticoagulant therapy  Antiplatelet agents  Coagulopathy  Alcohol abuse

10.  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.

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

13.  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.

14.  40%patients were receiving antiplatelet and anticoagulant therapy.  Coagulopathy obsereved in 2% patients.  Alcohol abuse present in 6% of patients.

15.  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.

16. Post-operative clinical improvement 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)

17.  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.

18.  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.)

19. 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. 27 cases(64.3%)with burr hole and sub dural drainage were discharged home for self care.

20.  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. 3 cases(7.2%) in burr hole group were sent to nursing home. 7 cases(4.6%)of craniotomy group and 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. 1 case(2.4%) of burr hole group died in hospital stay because of internal disease not directly attributable to CSDH.

22.  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.

24.  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.

25.  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%)

26.  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.

27. 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.

28.  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.

29.  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.

30.  Osteoclastic craniectomy might represent surgical option in complicated recurrent cases.