Sitting position awake craniostomy with drainage for chronic subdural hematoma: a viable alternative?

Milan Lepić; Stefan Mandić-Rajčević; Goran Pavlićević; Andrija Savić; Aleksandra Lokaj; Lukas Rasulić

doi:10.2298/VSP190611093L

Milan Lepić University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Stefan Mandić-Rajčević University of Belgrade, Innovation Centre of Faculty of Technology and Metallurgy, Belgrade, Serbia
Goran Pavlićević Military Medical Academy, Clinic for Neurosurgery, Belgrade, Serbia
Andrija Savić University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Aleksandra Lokaj University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Lukas Rasulić University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP190611093L

Keywords: hematoma, subdural, neurosurgical procedures, posture, recurrence, sitting position, treatment outcome

Abstract

Background/Aim. Chronic subdural hematoma (CSDH) is one of the most frequent neurosurgical conditions with an overall incidence ranging from 1.72 to 20.6 per 100,000 persons per year. The surgical procedure for CSDH is relatively simple and usually performed in the supine position. Reported reoccurrence rates range from 11.7% to 28%. Postperative pneumocephalus was previously identified as a sole predictor of reoccurrence. The aim of this study was to assess the advantage of the procedure in the sitting position in patients with CSDH and a possible impact on the reoccurrence rate. Methods. The study included 31 patients who underwent awake craniostomy with closed system drainage for CSDH (16 in supine and 15 in sitting position) in our department from December 2016 to March 2018. Results. A total of 22 males and 9 females were included in the study. The overall reoccurrence rate was 19% (22% and 18% in females and males, respectively). The reoccurrence was noted in 5 patients who had undergone surgery in the supine position, and in one case in the sitting position. Our results revealed a lower reoccurrence rate in patients undergoing surgery in the sitting position, although not reaching statistical significance [odds ratio (OR): 0.18, 95% confidence interval: 0.01–1.42, p = 0.172]. Conclusion. Craniostomy in the sitting position under local anesthesia is a safe, simple, and reliable procedure for CSDH treatment. Besides being very comfortable for the patient, according to our initial results, it might also lead to a lower reoccurrence rate, probably due to the better management of the air inflow, and consequent pneumocephalus.

References

Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Per-spective. World Neurosurg 2017; 108: 948‒53.

Yang W, Huang J. Chronic Subdural Hematoma: Epidemiology and Natural History. Neurosurg Clin N Am 2017; 28(2): 205‒10.

Montano N, Stifano V, Skrap B, Mazzucchi E. Management of residual subdural hematoma after burr-hole evacuation. The role of fluid therapy and review of the literature. J Clin Neu-rosci 2017; 46: 26‒9.

Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haemato-ma: inflammation, angiogenesis and implications for pharma-cotherapy. J Neuroinflammation 2017; 14(1): 108.

Novaković N, Lepić M, Minić L, Radenović K, Rotim A, Rasulić L. Combined Treatment of Ruptured Middle Cerebral Artery Aneurysm Followed by Subarachnoid Hemorrhage and Acute Subdural Hematoma in Multiple Aneurysm Disease of Cere-bral Blood Vessels: Case Report. Acta Clin Croat 2016; 55(4): 659‒62.

Welling LC, Welling MS, Teixeira MJ, Figueiredo EG. Chronic Subdural Hematoma: So Common and So Neglected. World Neurosurg 2018; 111: 393‒4.

Liu W, Bakker NA, Groen RJ. Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 2014; 121(3): 665‒73.

Winn HR. Youmans and Winn Neurological Surgery E-Book. 7th ed. Philadelphia, PA: Elsevier; 2016.

Buchanan IA, Mack WJ. Minimally Invasive Surgical Approach-es for Chronic Subdural Hematomas. Neurosurg Clin N Am 2017; 28(2): 219‒27.

Rasulić L, Lepić M. Neurosurgical clinical practice guidelines and recommendations: Experience, Evidence and Enrich-ment. World Neurosurg 2019; 26: 76‒8.

Mori K, Maeda M. Surgical treatment of chronic subdural he-matoma in 500 consecutive cases: clinical characteristics, sur-gical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001; 41(8): 371‒81.

You C G, Zheng XS. Postoperative pneumocephalus increases the recurrence rate of chronic subdural hematoma. Clin Neu-rol Neurosurg 2018; 166: 56‒60.

Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, et al. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg 2017; 127(1): 182‒8.

Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures. J Clin Neurosci 2013; 20(1): 32‒4.

Jadik S, Wissing H, Friedrich K, Beck J, Seifert V, Raabe A. A standardized protocol for the prevention of clinically relevant venous air embolism during neurosurgical interventions in the semisitting position. Neurosurgery 2009; 64(3): 533‒8; discus-sion 8‒9.

R Core Team (2018). R: A language and environment for sta-tistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available online at https://www.R-project.org/.

Subirana I, Sanz H, Vila J. Building Bivariate Tables: The compareGroups Package for R. J Statistical Software 2014; 57(12): 1‒16.

Wickham H. Ggplot2 Elegant Graphics for Data Analysis. 2nd ed. New York: Springer; 2009.

Kanyi JK, Ogada TV, Oloo MJ, Parker RK. Burr-Hole Crani-ostomy for Chronic Subdural Hematomas by General Sur-geons in Rural Kenya. World J Surg 2018; 42(1): 40‒5.

Desai VR, Scranton RA, Britz GW. Management of Recurrent Subdural Hematomas. Neurosurg Clin N Am 2017; 28(2): 279‒86.

Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M, Yama-gata S. Independent predictors for recurrence of chronic sub-dural hematoma: a review of 343 consecutive surgical cases. Neurosurgery 2008; 63(6): 1125‒9; discussion 1129.

Abouzari M, Rashidi A, Rezaii J, Esfandiari K, Asadollahi M, Aleali H, et al. The role of postoperative patient posture in the recurrence of traumatic chronic subdural hematoma after burr-hole surgery. Neurosurgery 2007; 61(4): 794-7; discus-sion 797.

Chon KH, Lee JM, Koh EJ, Choi HY. Independent predictors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien) 2012; 154(9): 1541‒8.

Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H, Endo S. Independent predictors of recurrence of chronic sub-dural hematoma: results of multivariate analysis performed us-ing a logistic regression model. J Neurosurg 2003; 98(6): 1217‒21.

Kamenova M, Lutz K, Schaedelin S, Fandino J, Mariani L, Soleman J. Does Early Resumption of Low-Dose Aspirin After Evacu-ation of Chronic Subdural Hematoma With Burr-Hole Drain-age Lead to Higher Recurrence Rates? Neurosurgery 2016; 79(5): 715‒21.

Kwon CS, Al-Awar O, Richards O, Izu A, Lengvenis G. Predict-ing Prognosis of Patients with Chronic Subdural Hematoma: A New Scoring System. World Neurosurg 2018; 109: e707‒e14.

Stanisić M, Pripp H. A Reliable Grading System for Prediction of Chronic Subdural Hematoma Recurrence Requiring Re-operation After Initial Burr-Hole Surgery. Neurosurgery 2017; 81(5): 752‒60.

Wang QP, Yuan Y, Guan JW, Jiang XB. A comparative study of irrigation versus no irrigation during burr hole craniostomy to treat chronic subdural hematoma. BMC Surg 2017; 17(1): 99.

Wang W, Liu H, Yang J. Burr hole craniostomy irrigation with and without drainage during surgical treatment of chronic subdural hematoma: A retrospective study of 87 cases. Turk Neurosurg 2017; doi: 10.5137/1019-5149.JTN.19747-16.2.

Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, et al. The sitting position in neurosurgery: indica-tions, complications and results. a single institution experience of 600 cases. Acta Neurochir (Wien) 2013; 155(10): 1887‒93.