ORIGINAL ARTICLE

Recurrence of chronic subdural haematomata with and without

post-operative drainage
JAKOB G. CARLSEN
1,2
, SREN CORTNUM
2
& JENS C. SRENSEN
1
1
Department of Neurosurgery, Aarhus University Hospital, Denmark,
2
Department of Neurosurgery, Aalborg Hospital,
Denmark
Abstract
Chronic subdural haematoma is a common disease causing morbidity and mortality. Recurrence after surgical treatment is
common, varying from 5% to 30% of cases. Several methods for reducing recurrence have been advocated. The aim of this
study was to investigate the effect of post-operative subdural drainage. Three hundred forty-four patients were included in a
retrospective study. Treatment was performed by burr hole irrigation. Groups were separated into those with post-operative
drainage compared to those without. Recurrence occurred in 14% in the drained group, signicantly less than 26% in the
undrained group (p 0.011). There were no differences in the complication rates. Post-operative drainage reduces
recurrence of chronic subdural haematoma without increasing the complication rate. These results support those reported in
several other studies. We recommend the use of post-operative subdural drainage.
Key words: Chronic subdural haematoma, subdural drainage, recurrence rate.
Background
Chronic subdural haematoma is a common disease,
with an incidence of 5 per 100,000 per year, and
causes serious morbidity and mortality. Surgery is
the preferred treatment and clinical outcome is often
good. Recurrence is the major problem after
surgery, reported rates varying from 5% to 30%,
and there has not been until recently much research
on this topic.
1
Treatment is usually uncomplicated. Burr hole
evacuation is used in most cases, but when the CT
scan reveals one or more membranes or fresh
components in the haematoma, evacuation via
craniotomy maybe the preferred option, though some
reserve this for when simple burr hole drainage is
ineffective, as often the patients are elderly with
signicant co-morbidity. The most controversial part
of the burr hole procedure is whether or not to place
a drain in the subgaleal space lying over the burr hole
or in the subdural space. Surveys reveal that many
neurosurgeons are unconvinced about the role and
effectiveness of drains after burr hole evacuation.
2
This retrospective study considers whether the use of
post-operative drainage of the subdural space im-
proves the recurrence rate.
Methods
Patients
All medical charts for patients, with the operative
classication code for evacuation of chronic subdural
haematoma from 2004 to 2009, were evaluated.
Patients were recruited from the Central Denmark
Region. This region has 1.2 million inhabitants, all
assigned to one neurosurgical department, which
ensures that only very few patients are lost in follow-
up. All patients unavailable for follow-up, re-oper-
ated because of acute subdural haematoma and
primarily operated by craniotomy, were excluded
from the analysis. Patients assigned to prospective
studies using different treatment protocols were also
excluded.
Recurrence was dened by the need for re-
operation on the same side within the rst 6 months
of the primary operation; bilateral haematomas were
analyzed by treating the haematomata as one case
when receiving the same treatment, consistent with
previous studies.
3
Statistical analysis was done using the Fishers
exact test or the w
2
tests for categorical frequency
comparison between groups and a one-tailed value of
p 50.05 was considered signicant.
Correspondence: Jakob Gram Carlsen, Nrrebrogade 44, DK-8000 Aarhus, Denmark. E-mail: jakocarl@rm.dk
Received for publication 24 August 2010. Accepted 25 January 2011.
British Journal of Neurosurgery, June 2011; 25(3): 388390
ISSN 0268-8697 print/ISSN 1360-046X online 2011 The Neurosurgical Foundation
DOI: 10.3109/02688697.2011.558945
Treatment
The vast majority were treated in local anaesthesia. A
single burr hole was drilled over the maximum width
of the haematoma. The dura mater was opened by a
cruciate incision. If judged safe, membranes were
opened under the burr hole, and the subdural
haematoma uid was gently rinsed from the subdural
space using Ringers lactate until a clear liquid was
discharged. The cavity was lled with Ringers lactate
and then, depending on the surgeons preference and
choice, a soft drain was then placed, either over the
burr hole in the subgaleal space, or inserted into the
subdural space and connected to a soft drainage bag,
allowing drainage by siphoning. No vacuum was
used. The drain was removed the following day. A
CT scan was performed 34 weeks post-operatively
(earlier if there was suspicion of recurrence) and
evaluated by a radiologist and the surgeon. Re-
operation was performed in case of symptomatic
recurrence or if the control scan revealed signicant
enlargement of the subdural haematoma.
Results
In total, 463 medical charts from patients operated
for chronic subdural haematoma were identied. Of
these 344 patients fullled the inclusion criteria
for further analysis and were enrolled in the study
(Table I).
Patients were divided into two groups depending
on the use of drainage. There were no statistical
differences between groups in respect of the demo-
graphic data age, gender co-morbidity.
The combined recurrence rate was 18.9%; how-
ever, if a drain was not used the recurrence rate was
26.1% which decreased to 14.1% in the group in
whom drains were used. This reduction was statis-
tically signicant, p 0 (Table II).
Complications were rare. In the subdural
drained group, 0.9% of the operations resulted in
complications, comparing to 2.2% in the non-drai-
ned group (p 0.397). Complications were all acute
subdural haematomas. No post-operative infections
were found in the cases examined. There were two
post-operative deaths (one in each group). The
deaths were not related to the surgical procedure.
Discussion
This study of 344 patients treated for chronic subdural
haematoma by a single burr hole reveals a signicantly
lower recurrence rate with the use of post-operative
drainage compared to non-drainage. Complications
were few with no difference between groups. These
results support those of several other studies. In a
large, single-centre randomised control trial (RCT)
reported after our study commenced analysis Santar-
ius et al. evaluated the use of drainage after a two burr
hole procedure under general anaesthesia and found a
recurrence rate of 9.3% with the use of drainage
compared to 24% without drainage and a reduced 6
months mortality rate with drainage.
3
Other studies have also reported a lower recur-
rence rate with the use of drainage, with rates varying
from 3.1% to 10% with the use of drainage compared
to 19%33% without drainage.
48
Other studies
suggest that the effect of drainage could be optimized
by increasing drainage time and volume.
9,10
In our literature review, we have not come across
any studies supporting non-drainage, nor revealing a
higher complication rate with drainage, though of
course absence of evidence is not evidence of
absence!.
We speculate that the slightly higher recurrence
rate found in our study compared to some of the
other studies could be due to differences in surgical
methods. A difference with the Santarius group is the
use of multiple burr holes, general anaesthesia (which
might mean the washout was more effective) and
placement of the drain into the subdural space
(which might make drainage more effective. The
similarity in the undrained group between our
studies and theirs argues more in favour of a
difference related to simply to the drainage proce-
dure. We use a single burr hole procedure while
others report on the basis of a two burr hole
procedure.
3,4
This difference in operative methods
could also be responsible for some of the difference,
although one study fails to nd a benet of double
versus single burr hole on recurrence rate.
11
TABLE I. Enrolment analysis
TABLE II. Recurrence rates following single burr hole irrigation
with postoperative drainage vs. non-drainage (p 0.011)
Treated Recurrence Recurrence rate (%)
Drained 206 29 14.1
Non-drained 138 36 26.1
Combined 344 65 18.9
Note: Combined recurrence rate also shown.
Chronic subdural haematoma, drainage 389
At our institution the tradition is to place the drain
over the burr hole to eliminate the risk of cortical
damage from the drain whereas some other centres
prefer to place the drain directly into the subdural
space. This might inuence outcome. However, we
have not been able to identify any studies focusing on
this potential difference. We believe that the short
distance and free ow of liquid through the burr hole
does not alter drainage rate or volume compared to
placing the drain under the dura. Combined with a
low complications rate and comparable recurrence
rates it has so far seemed to be a sensible placement
of the drain.
Our complication rate is low and in accordance
with previous reports.
3,4,12,13
In both groups we
experienced acute subdural haematomas with no
statistical difference between groups. Two post-
operative deaths were found, neither related to the
surgical procedure. We found no intracranial infec-
tions and no veried trauma to the underlying brain
was reported.
Conclusions
The efciency and risk of subdural drainage has been
debated and left to the personal preference of the
surgeon for many years now. Our study shows that
the use of post-operative drainage after single burr
hole irrigation of chronic subdural haematoma is safe
and efcient. Chronic subdural haematoma recur-
rence is signicantly less, with than without drainage
(14.1% vs. 26.1%, p 0.011).
The ndings in our study provide an important
validation of the results from the recent RCT by
Santarius et al. We, accordingly, also recommend the
use of post-operative drainage of the subdural space
for the treatment of chronic subdural haematoma.
Acknowledgements
The authors acknowledge the secretarial assistance of
Ms. Aase Fuglendorf, and the discussion of literature
and cases with Drs. Jens Jakob Riis and Preben
Srensen.
Declaration of interest: The authors report no
conicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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