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Abstract BACKGROUND The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes. OBJECTIVE To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD. METHODS Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay. RESULTS Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups. CONCLUSION Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice Graphical Abstract Graphical Abstract

Background Chronic subdural haematoma (CSDH) is a common condition that is effectively managed by burrhole drainage but requires repeat surgery in a significant minority of patients. The Cambridge Chronic Subdural Haematoma Trial (CCSHT) was a randomised controlled study that showed placement of subdural drains for 48 h following burrhole evacuation significantly reduces the incidence of reoperation and improves survival at 6 months. The present study examined the long-term survival of the patients in the trial. Methods In the original trial patients at a single neurosurgical centre from 2004–2007 were randomly assigned to receive a drain (n = 108) or no drain (n = 107) following burrhole drainage of CSDH. We ascertained whether the trial patients were alive in February 2016—a minimum of 8 years following enrollment—via the UK NHS tracing service. Survival was compared between the trial groups and against expected survival for the UK general population matched for age and sex. Results At 5 years following surgery the drain group continued to have significantly better survival than the no drain patients (p = 0.027), but this was no longer apparent at 10 years. Survival of patients in the drain group did not differ significantly from that of the general population whereas patients who did not receive a drain had significantly lower survival than expected (p = 0.0006). Conclusion Subdural drains following CSDH evacuation are associated with improved long-term survival, which appears similar to that expected for the general population of the same age and sex. All patients having burrhole CSDH evacuation should receive a drain as standard practice unless specifically contraindicated.

Background Chronic subdural hematoma (CSDH) is a common acute or subacute neurosurgical condition, typically treated by burr-hole evacuation and drainage. Recurrent CSDH occurs in 5–20% of cases and requires reoperation in symptomatic patients, sometimes repeatedly. Postoperative subdural drainage of maximal 48 h is effective in reducing recurrent hematomas. However, the shortest possible drainage time without increasing the recurrence rate is unknown. Methods DRAIN-TIME 2 is a Danish multi-center, randomized controlled trial of postoperative drainage time including all four neurosurgical departments in Denmark. Both incapacitated and mentally competent patients are enrolled. Patients older than 18 years, free of other intracranial pathologies or history of previous brain surgery, are recruited at the time of admission or no later than 6 h after surgery. Each patient is randomized to either 6, 12, or 24 h of passive subdural drainage following single burr-hole evacuation of a CSDH. Mentally competent patients are asked to complete the SF-36 questionnaire. The primary endpoint is CSDH recurrence rate at 90 days. Secondary outcome measures include SF-36 at 90 days, length of hospital stay, drain-related complications, and complications related to immobilization and mortality. Discussion This multi-center trial will provide evidence regarding the shortest possible drainage time without increasing the recurrence rate. The potential impact of this study is significant as we believe that a shorter drainage period may be associated with fewer drain-related complications, fewer complications related to immobilization, and shorter hospital stays—thus reducing the overall health service burden from this condition. The expected benefits for patients’ lives and health costs will increase as the CSDH patient population grows. Trial registration ISRCTN Registry ISRCTN15186366 . Registered in December 2020 and updated in October 2021. This protocol was developed in accordance with the SPIRIT Checklist and by use of the structured study protocol template provided by BMC Trials.

Background Spontaneous intracranial hypotension syndrome (SIH)-induced chronic subdural hematoma (CSDH) often presents with orthostatic headaches but is frequently misdiagnosed, leading to inappropriate treatments like fatal hematoma drainage instead of epidural blood patches. In clinical practice, reliable and quantitative diagnostic criteria for this condition are lacking. This study uses initial CT scans to identify novel radiographic markers for accurately diagnosing SIH-induced CSDH. Methods We retrospectively reviewed 310 consecutives hospitalized CSDH cases from January 2008 to May 2023. Among these, 54 were bilateral, with 11 induced by SIH; two secondary intracranial hypotension cases were excluded. We analyzed nine primary SIH-induced cases, comparing clinical and preoperative CT features with 43 non-SIH bilateral cases, focusing on the parasagittal subdural space (PSS) volume. We also conducted propensity score matching to validate our findings. Results Patients with SIH-induced bilateral CSDH were significantly younger than those without SIH (mean age 54.7 vs. 76.2 years; P  < 0.001). Orthostatic headache was more common in the SIH group (66.7% vs. 2.3%, P  < 0.001). While hematoma volumes were similar, PSS volume was significantly larger in the SIH group (mean 15.0 vs. 5.1 mL, P  = 0.007). ROC analysis identified an exploratory PSS cut-off of 11.1 mm², which yielded a sensitivity of 86% and a specificity of 66.7% ( P  = 0.009). Linear regression and qualitative assessments indicated a significant association between PSS volume and crural-and-ambient cistern obliteration, as well as cerebellar ptosis in the SIH group ( P  < 0.001). Conclusion A preserved PSS on coronal CT represents a novel, quantitative marker for SIH-induced CSDH and may serve as a practical diagnostic clue, particularly when MRI is unavailable.

Twist drill craniostomy with closed drainage system for 48-hour duration is an effective treatment of chronic subdural hematomas.Twist drill craniostomy with closed drainage system for 48-hour duration is an effective treatment of chronic subdural hematomas.

Objective: Chronic subdural hematoma (CSDH) recurs after surgical evacuation in 5-30% of patients. Inserting subdural drain might reduce the recurrence rate, but is not commonly practiced. There are few prospective studies to evaluate the effect of subdural drains. Materials and Methods: A prospective randomized study to investigate the effect of subdural drains in the on recurrence rates and clinical outcome following burr-hole drainage (BHD) of CSDH was undertaken. During the study period, 246 patients with CSDH were assessed for eligibility. Among 200 patients fulfilling the eligibility criteria, 100 each were assigned to \"drain group\" (drain inserted into the subdural space following BHD) and \"without drain group\" (subdural drain was not inserted following BHD) using random allocation software. The primary end point was recurrence needing re-drainage up to a period of 6 months from surgery. Results: Recurrence occurred in 9 of 100 patients with a drain, and 26 of 100 patients in without drain group (P = 0.002). The mortality was 5% in patients with drain and 4% in patients without drain group (P = 0.744). The medical and surgical complications were comparable between the two study groups. Conclusion: Use of a subdural drain after burr-hole evacuation of a CSDH reduces the recurrence rate and is not associated with increased complications.

Background The usage of a drain following evacuation of a chronic subdural haematoma (CSDH) is known to reduce recurrence. In this study we aim to compare the clinical outcomes and recurrence rate of utilising two different types of drains (subperiosteal and subdural drain) following drainage of a CSDH. Methods Prospective randomised single-centre study analysing 50 patients who underwent CSDH treatment. Two types of drains, subperiosteal (SPD) and subdural (SDD), were utilised on consecutive alternate patients following burr-hole craniostomy, with a total of 25 patients in each group. The drains were left in for 48-h duration and then removed. The modified Rankin Scale (mRS) was used for outcome measurement at 3 and 6 months. Results Data analysis was performed by unpaired t test with Welch’s correction. It was observed that none of the patients in either group had haematoma recurrence during a 6-month follow-up, and a significant difference in outcome was noted at 6 months ( p  = 0.0118) more than at 3 months ( p  = 0.0493) according to the statistical analysis. Postoperative seizure and inadvertent placement of the subdural drain into the brain parenchyma were the two complications noted in this study. Anticoagulant use prior to the surgery did not affect the outcome in either group. Conclusions We conclude there was no recurrence of CSDH utilising the SDD and SPD following burr-hole craniostomy. The mRS measurement at the 6-month follow-up was found to be statistically significant, with better outcomes with utilisation of the SPD. The SPD may thus prove to be more beneficial than the SDD in the treatment of CSDH. A multi-centre study with a larger group of patients is recommended to reinforce the results from our study.

A prospective randomised 2-year follow-up study on patients undergoing lumbar disc herniation surgery. The objective was to investigate the relationship between peridural scarring and clinical outcome, the scar development 6 and 24 months postoperatively by using MRI, and if ADCON-L (a bioresorbable carbohydrate polymer gel) has an effect on scar size and/or improve patients’ outcome after lumbar disc herniation surgery. The association between peridural scarring and recurrent pain after lumbar disc herniation surgery is debated. Numerous materials have been used in attempts to prevent or reduce postoperative peridural scarring; however, there are conflicting data regarding the clinical effects. The study included 119 patients whose mean age was 39 years (18–66); 51 (47%) were women. Sixty patients (56%) were perioperatively randomised to receive ADCON-L, and 48 (44%) served as controls. All patients underwent MRI at 6 and 24 months postoperatively, and an independent radiologist graded the size, location and development of the scar, by using a previously described scoring system. Pre- and 2-year postoperatively patients graded their leg pain on a visual analogue scale (VAS). At the 2-year follow-up patients rated their satisfaction with treatment (subjective outcome) and were evaluated by an independent neurologist (objective outcome), using MacNab score. There was no relationship between size or localisation of the scar and any of the clinical outcomes (VAS, subjective and objective outcome). The scar size decreased between 6 and 24 months in 49%, was unchanged in 42% and increased in 9% of the patients. Patients treated with ADCON-L did not demonstrate any adverse effects, nor did they demonstrate less scarring or better clinical outcome than control patients. No significant association between the presence of extensive peridural scar or localisation of scar formation and clinical outcome could be detected in the present study. Further, no positive or negative effects of ADCON-L used in disc herniation surgery could be seen.