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ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 96-98

Comparative study of subgaleal and subdural closed drain in surgically treated cases of chronic subdural hematoma


Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission22-Mar-2020
Date of Decision06-Sep-2020
Date of Acceptance15-Oct-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Shivender Sobti
11/12 B, Opposite BCM School, Basant Avenue, Near Dugri, Phase 2, Ludhiana - 141 013, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_101_20

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  Abstract 

Background: Chronic subdural hematoma (CSDH) is seen most common in geriatric patients, and trauma is the most important reason for CSDH. Operative treatment of CSDH in symptomatic patients is yet the gold standard of therapy because it allows decompression of the subdural space and aids improvement in neurological status. Burr-hole craniostomy is the most common accepted treatment for CSDH. There is still controversy regarding which type of drain placement is best in the outcome: subdural or subgaleal drain. Aim: The aim of the study was to compare the outcome of subgaleal versus subdural drain in surgically treated patients of CSDH. Materials and Methods: Patients were assigned by simple random sampling in two groups. The study was conducted from February 2016 to July 2017. A total of 70 patients were enrolled into the study and were divided in two groups (Group 1 – Subgaleal drain; Group 2 – Subdural drain). Statistical analysis was done using Chi-square and t-test. Outcome was assessed at the end of hospital stay by modified Rankin scale. Postoperative computed tomography scan was done after 24 h of surgery. Results: This study concluded that both types of drains are equally effective for the treatment of CSDH. There is a statistically significant difference in the occurrence of seizure in both the groups as there was no seizure in subgaleal drain group compared to 5 (14.3%) patients who had seizures postoperatively in subdural drain group (P = 0.020). There was insignificant difference with respect to preoperative Glasgow Coma Scale/sex/preoperative hematoma volume/postoperative hematoma volume/preoperative midline shift. Conclusion: Subgaleal drain is safe and technically easy, as subgaleal drain has no direct contact with brain parenchyma, thus less chances of brain laceration, intracerebral hematoma formation, and seizures.

Keywords: Burr hole, chronic subdural hematoma, seizures, subdural drain, subgaleal drain


How to cite this article:
Singh J, Sobti S, Chaudhary A, Chaudhary V, Garg T. Comparative study of subgaleal and subdural closed drain in surgically treated cases of chronic subdural hematoma. Asian J Neurosurg 2021;16:96-8

How to cite this URL:
Singh J, Sobti S, Chaudhary A, Chaudhary V, Garg T. Comparative study of subgaleal and subdural closed drain in surgically treated cases of chronic subdural hematoma. Asian J Neurosurg [serial online] 2021 [cited 2021 Apr 14];16:96-8. Available from: https://www.asianjns.org/text.asp?2021/16/1/96/309624


  Introduction Top


Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. The incidence in the general population is 5/100,000/year and is more common in aged population, i.e., 70 years and older with an incidence of 58/100,000.[1] Surgical treatment is mainly considered for treatment with burr hole, twist drill, and craniotomy as the preferred procedures.[2],[3] The incidence of CSDH is gradually increasing as a result of aging population and associated medical conditions like patients on hemodialysis/antiplatelets and anticoagulants. Studies have been done regarding the use of drain or no drain in these procedures.[4],[5] Few studies have compared the site of drain in CSDH. The present study is done to evaluate the role of site of drain placement in CSDH.


  Materials and Methods Top


Patients were assigned by simple random sampling in two groups. The study was conducted from February 2016 to July 2017. A total of 70 patients were enrolled in the study and were divided in two groups (Group 1 – subgaleal drain; Group 2 – subdural drain). The study was a prospective study. Appropriate institutional ethics committee clearance and patients' consent were obtained. Patients were investigated using computed tomography scan (CT scan). Patients with CSDH having mass effect/worsening condition despite optimal conservative management were included in the study. Patients in whom intraoperative conditions warranted a craniotomy or in whom subdural drain insertion was not feasible were excluded from the study. Statistical analysis was done using Chi-square and t-test. The outcome was assessed at the end of hospital stay by modified Rankin scale (mRS). Postoperative CT scan was done after 24 h of surgery. The number of burr holes was based on surgeon's discretion. Subdural hematoma (SDH) cavity was irrigated copiously with normal saline until clear return came out.

Placement of drain

Group I – The subgaleal space was dissected widely using a blunt dissector and a subgaleal drain was placed. The end of drain was kept away from the burr hole site to avoid any accidental slippage of the tube into the subdural cavity [Figure 1].[6]
Figure 1: Diagram showing placement of subgaleal drain

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Group II – The subdural drain was placed in subdural space.

Romovac suction drain (Romson) was used. The drains were taken out from about 5 cm away from scalp incision. The incision was closed in two layers. The drain was connected to a soft collection bag that was kept in a dependent position. Negative pressure was not applied.


  Results Top


Seventy patients were enrolled in the study; 35 patients each were enrolled in Group I (with subgaleal drain) and in Group II (with subdural drain).

The common clinical symptoms were headache and hemiparesis. Vomiting is seen in ten patients. Dementia and incontinence were other features. Most of the patients had Glasgow Coma Scale (GCS) 10–15. Sixty-four patients had unilateral SDH and 6 patients had bilateral SDH. Single burr hole was made in 31 patients in Group I and 27 patients in Group II. Double burr holes were made in 2 patients in Group I and 4 patients in Group II. Bilateral burr holes were made in 6 patients. The mean volume was 122.63 mL in Group I and 119.86 ml in Group II. Midline shift in Group I was 6.44 mm and 6.3 mm in Group II. Complications were seen in both the groups. Pneumocephalus was the most common complication which was seen equally in both the groups. Seizures were seen only in subdural group (five patients), while no patient in subgaleal group had seizures. Redo surgery was done in one patient in subgaleal drain group (Group I). Two patients in Group II and one patient in Group I developed intracerebral hematoma (ICH). The difference of seizures in both the groups was found to be significant. The two groups were comparable with regard to age/preoperative GCS/sex/preoperative hematoma volume/preoperative midline shift/residual hematoma/postoperative pneumocephalus [Table 1] and [Table 2].
Table 1: Comparison between two groups

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Table 2: Complications in both the groups

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  Discussion Top


CSDH usually forms in the elderly population. The processes involved in the formation of CSDH are angiogenesis, fibrinolysis, and inflammation. The membrane surrounding CSDH is a source of fluid exudation and hemorrhage. Angiogenic stimuli lead to the formation of blood vessels which are fragile, while the fibrinolytic processes lead to continuous hemorrhage as they prevent clot formation.[7] Santarius et al. demonstrated lower recurrence rates in patients in whom drain was used as compared to no drain group at 6-month follow-up. Gazzeri et al. and Zumofen et al.[8],[9] reported a case series of extracalvarial (subperiosteal/subgaleal) drain insertion following burr-hole craniostomy (BHC). The result showed recurrence rates comparable to previously published results in literature.

Chih et al.[10] observed a nonsignificant increase in complications in subdural drain group.

The common clinical symptoms in CSDH are headache and hemiparesis. In our study, the incidence of headache and hemiparesis was 68% and 64%, respectively.

Bellut et al.[11] published the results on comparison and recurrence in subdural and subgaleal drainage. Hematoma remnant in subgaleal and subdural groups was 6.2% and 1.5%, respectively, and favored subdural drain over subgaleal drain. Guilfoyle et al.[12] found subdural drain to be more effective in reducing the incidence of residual or recurrent hematoma that required reoperation. In our study, we found 31.4% of patients in subgaleal drain group and 22.9%of patients in subdural drain group were having postoperative residual hematoma but was insignificant (P = 0.420). The mean residual hematomas in both the groups were also not significant.

Incidence of subdural empyema has been reported to be in a range of 0%–6%. Gazzeri et al. and Zumofen et al.[8],[9] reported very low rate of subdural empyema in association with intracranial placement of a drain. In our study, we found one patient of subdural empyema in subdural drain group.

Gazerri et al.[8] and Zumofen et al.[9] reported intracranial hematoma with the use of subdural drain. We reported two cases of ICH in subdural group.

Seizure rates of 2%–19% have been reported in CSDH patients. Oral et al.[13] found subgaleal drainage as relatively less invasive, safe, as the drainage tube is not in direct contact with the brain tissue and membranes of CSDH. In our study, 4.3% of patients of subdural drain group had postoperative seizures, while there were no seizures in subgaleal group.

Mean mRS was the same in both the groups at the time of discharge in our study. Kaliaperumal et al.[14] concluded better mRS in the subgaleal group at 6-month follow-up. Insignificant difference in mean hospital stay was observed in both the groups. Yadav et al.[6] reported similar results.


  Conclusion Top


Recurrence rates after drainage of CSDH by BHC do not depend on drain position and number of burr holes. Seizure frequency and ICH formation rate are increased in patients having subdural drains. Larger studies having a larger number of patients have to be done to further investigate these findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N. Chronic subdural hematoma in elderly people: Present status on Awaji Island and epidemiological prospect. Neurol Med Chir (Tokyo) 1992;32:207-9.  Back to cited text no. 1
    
2.
Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: A questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 2008;22:529-34.  Back to cited text no. 2
    
3.
Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: A national survey and literature review. Can J Neurol Sci 2005;32:501-6.  Back to cited text no. 3
    
4.
Karibe H, Kameyama M, Kawase M, Hirano T, Kawaguchi T, Tominaga T. Epidemiology of chronic subdural hematomas. No Shinkei Geka 2011;39:1149-53.  Back to cited text no. 4
    
5.
Krupa M. Chronic subdural hematoma: A review of the literature. Part 1. Ann Acad Med Stetin 2009;55:47-52.  Back to cited text no. 5
    
6.
Yadav YR, Parihar V, Chourasia ID, Bajaj J, Namdev H. The role of subgaleal suction drain placement in chronic subdural hematoma evacuation. Asian J Neurosurg 2016;11:214-8.  Back to cited text no. 6
  [Full text]  
7.
Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KL, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: Inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017;14:108.  Back to cited text no. 7
    
8.
Gazzeri R, Galarza M, Neroni M, Canova A, Refice GM, Esposito S. Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma. Acta Neurochir (Wien) 2007;149:487-93.  Back to cited text no. 8
    
9.
Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery 2009;64:1116-21.  Back to cited text no. 9
    
10.
Chih AN, Hieng AW, Rahman NA, Abdullah JM. Subperiosteal drainage versus subdural drainage in the management of chronic subdural hematoma (a comparative study). Malays J Med Sci 2017;24:21-30.  Back to cited text no. 10
    
11.
Bellut D, Woernle CM, Burkhardt JK, Kockro RA, Bertalanffy H, Krayenbühl N. Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas. World Neurosurg 2012;77:111-8.  Back to cited text no. 11
    
12.
Guilfoyle MR, Hutchinson PJ, Santarius T. Improved long-term survival with subdural drains following evacuation of chronic subdural haematoma. Acta Neurochir (Wien) 2017;159:903-5.  Back to cited text no. 12
    
13.
Oral S, Borklu RE, Kucuk A, Ulutabanca H, Selcuklu A. Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma. North Clin Istanb 2015;2:115-21.  Back to cited text no. 13
    
14.
Kaliaperumal C, Khalil A, Fenton E, Okafo U, Kaar G, O'Sullivan M, et al. A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma. Acta Neurochir (Wien) 2012;154:2083-8.  Back to cited text no. 14
    


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    Tables

  [Table 1], [Table 2]



 

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