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Background Traumatic brain injury (TBI) is a major cause of long‐term disability and economic loss to society. The aim of this study was to assess the factors affecting mortality after TBI in a resource‐poor setting. Methods Chart review was performed for randomly selected patients who presented with TBI between 2013 and 2017 at St Mary's Hospital, Lacor, northern Uganda. Data collected included demographic details, time from injury to presentation, and vital signs on arrival. In‐hospital management and mortality were recorded. Severe head injury was defined as a Glasgow Coma Scale score below 9. Results A total of 194 patient charts were reviewed. Median age at time of injury was 27 (i.q.r. 2–68) years. The majority of patients were male (M : F ratio 4·9 : 1). Some 30·9 per cent of patients had severe head injury, and an associated skull fracture was observed in 8·8 per cent. Treatment was mainly conservative in 94·8 per cent of patients; three patients (1·5 per cent) had burr‐holes, four (2·1 per cent) had a craniotomy, and three (1·5 per cent) had skull fracture elevation. The mortality rate was 33·0 per cent; 46 (72 per cent) of the 64 patients who died had severe head injury. Of the ten surgically treated patients, seven died, including all three patients who had a burr‐hole. In multivariable analysis, factors associated with mortality were mean arterial pressure (P = 0·012), referral status (P = 0·001), respiratory distress (P = 0·040), severe head injury (P = 0·011) and pupil reactivity (P = 0·011). Conclusion TBI in a resource‐poor setting remains a major challenge and affects mainly young males. Decisions concerning surgical intervention are compromised by the lack of both CT and intracranial pressure monitoring, with consequent poor outcomes. Antecedentes La lesión cerebral traumática (traumatic brain injury, TBI) es un insulto al cerebro causado por una fuerza física externa que produce un estado de conciencia disminuido o alterado, lo que resulta en un deterioro de las capacidades cognitivas o del funcionamiento físico. Es una causa importante de discapacidad a largo plazo y pérdida económica para la sociedad. El objetivo de este estudio fue evaluar los factores que afectan a la mortalidad después de una TBI en un entorno de escasos recursos. Métodos Se realizó la revisión de historias clínicas de pacientes seleccionados al azar que habían presentado una TBI entre 2013 y 2017 en el Hospital St. Mary's, un hospital privado sin ánimo de lucro ubicado en el distrito de Gulu, Lacor, en el norte de Uganda. Se recogieron datos de las características demográficas, intervalo de tiempo entre la lesión y la atención médica, y signos vitales a la llegada al hospital. Se registró también el manejo hospitalario y la mortalidad. El traumatismo craneal grave se definió como aquel con una escala de coma de Glasgow (Glasgow Coma Scale, GCS) por debajo de 9. Resultados Se revisaron 194 historias clínicas de pacientes. La mediana de edad en el momento del traumatismo fue de 27 (rango intercuartílico de 2 a 68) años. La mayoría eran varones con una relación varón:mujer de 4,9:1. En el 38,1% de los casos los traumatismos craneales fueron calificados como graves y se observó una fractura de cráneo asociada en el 8,8% de los pacientes. Los tratamientos ofrecidos fueron principalmente conservadores en el 94,9%; tres pacientes (1,6%) precisaron trépanos, en cuatro pacientes (2,1%) se realizó una craneotomía y otros tres pacientes (1,6%) precisaron elevación de una fractura craneal con hundimiento. La mortalidad fue del 33,0%; El 71,9% de ellos tenían un traumatismo craneal grave. Entre los pacientes tratados quirúrgicamente, siete (70%) murieron, incluidos los tres pacientes en los que se realizó un trépano. Los factores asociados con la mortalidad en el análisis multivariable fueron la presión arterial media (P < 0,05), el estado en el traslado (P < 0,05), la dificultad respiratoria (P = 0,040), el traumatismo craneal grave (P = 0,012) y la reactividad pupilar (P = 0,011). Conclusión El TBI en un entorno con pocos cursos continúa siendo un desafío importante, afectando principalmente a varones jóvenes. Las decisiones relativas a la intervención quirúrgica y el momento de su práctica están seriamente comprometidas por la falta de disponibilidad de tomografía computarizada (TAC) y monitorización de la presión intracraneal, lo que conlleva unos pobres resultados. Traumatic brain injury (TBI) in 194 patients in a resource‐poor setting was analysed. Some 30·9 per cent had severe TBI, and associated skull fracture was observed in 8·8 per cent. Treatments offered were mainly conservative. The mortality rate was 33·0 per cent, with 72 per cent resulting from severe head injury. Seven of ten surgically treated patients died, including all three patients who had received a burr‐hole. Factors associated with mortality in multivariable analysis were mean arterial pressure, referral status, respiratory distress, severe head injury and pupil reactivity. TBI remains a major challenge in resource‐poor settings, with the younger male population mainly involved. Decisions regarding interventions are greatly compromised by the lack of CT and intracranial pressure monitoring. Mortality remains high

PurposeTo analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome.MethodsAmong adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery—trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied.ResultsOf 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients.ConclusionsReoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

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 In Denmark, the current treatment of patients with symptomatic chronic subdural hematoma (CSDH) is single burr hole hematoma evacuation followed by 24-h passive subdural drainage. However, recent studies indicate that 24-h active subperiosteal drainage may be safer and have fewer recurrences. The upcoming SUPERDURA trial will investigate 24-h active subperiosteal drainage versus 24-h passive subdural drainage following single burr-hole evacuation of symptomatic CSDH. This study presents the statistical analysis plan for the SUPERDURA trial. Methods SUPERDURA is a national multi-center non-inferiority randomized clinical trial. The primary outcome is a composite of 90-day mortality and ipsilateral recurrent CSDH requiring reoperation within the 90-day observation period. Secondary outcomes are 90-day simplified modified Rankin Scale questionnaire (smRSq) score, complications related to surgery, postoperative serious adverse events during the admission and at 90 days, and length of hospitalization. Exploratory outcomes are smRSq score as an ordinal outcome, each component of the primary outcome, and discharge destination. A total of 354 participants must be included (177 in each intervention group) in the study to achieve a stable power > 90% with an alpha of 5% for non-inferiority testing of the primary composite outcome with a margin at 7% absolute risk increase. The allocation sequence and block sizes are blinded to the investigators. Interim analyses for safety and efficacy/futility will be performed after follow-up is completed for 120 and 240 participants, respectively. A Data Safety Monitoring Committee charter has been created following published recommendations. Final analysis will be done by two statisticians blinded to the intervention, creating two abstracts that are unblinded once approved by the study steering committee. Discussion The proposed analysis plan is designed in accordance with current guidelines, has clinically important primary and secondary outcomes, and was submitted before the inclusion of the first participant in the SUPERDURA trial to limit bias and increase study transparency and reproducibility. Trial registration ClinicalTrials.gov identifier NCT06621407.

BackgroundAn external ventricular drain (EVD) is typically indicated in the presence of hydrocephalus and increased intracranial pressure (ICP). Procedural challenges have prompted the development of different methods to improve accuracy, safety, and logistics.ObjectivesEVD placement and complications rates were compared using two surgical techniques; the standard method (using a 14-mm trephine burrhole with the EVD tunnelated through the skin) was compared to a less invasive method (EVD placed through a 2.7–3.3-mm twist drill burrhole and fixed to the bone with a bolt system).MethodsRetrospective observational study in a single-centre setting between 2008 and 2018. EVD placement was assessed using the Kakarla scoring system. We registered postoperative complications, surgery duration and number of attempts to place the EVD.ResultsTwo hundred seventy-two patients received an EVD (61 bolt EVDs, 211 standard EVDs) in the study period. Significant differences between the bolt system and the standard method were observed in terms of revision surgeries (8.2% vs. 21.5%, p = 0.020), surgery duration (mean 16.5 vs. 28.8 min, 95% CI 7.64, 16.8, p < 0.001) and number of attempts to successfully place the first EVD (mean 1.72 ± 1.2 vs. 1.32 ± 0.8, p = 0.017). There were no differences in accuracy of placement or complication rates.ConclusionsThe two methods show similar accuracy and postoperative complication rates. Observed differences in both need for revisions and surgery duration favoured the bolt group. Slightly, more attempts were needed to place the initial EVD in the bolt group, perhaps reflecting lower flexibility for angle correction with a twist drill approach.

ObjectivesThe objective of this study was to investigate the utility of the days alive and out of hospital (DAOH) metric within a cohort of patients undergoing burr-hole drainage of a chronic subdural haematoma (CSDH). We evaluate the validity of the DAOH metric in a national CSDH cohort and examine how the DAOH metric compares to its constituent outcomes (mortality and hospital bed days) at an organisational level.MethodsRetrospective cohort study using Hospital Episode Statistics data linked to the national death registry to identify patients who underwent burr-hole drainage of CSDH in English National Health Service neurosurgical units between 1 April 2013 and 31 March 2020. Construct validity was assessed by measuring the patterns of DAOH across categories of known perioperative risk factors. Variation between units in the risk-adjusted values for DAOH, postoperative mortality and days in hospital was explored using funnel plots. Linear regression and logistic regression were used to derive the risk-adjusted rates.ResultsOverall, 16 450 patients who underwent at least one burr-hole drainage of CSDH were identified during the time period. The median 30-day DAOH was 16 (IQR, 0–24); the median for the 90-day DAOH was 74 (42–84), and was better at measuring the complete stay associated with the index admission. Worse 90-day DAOH values were associated with older age, increasing comorbidities and greater frailty. Risk-adjusted 90-day DAOH values for neurosurgical units varied more markedly than for its constituent outcomes.ConclusionsThe 90-day DAOH looks to be a valid outcome metric for patients undergoing burr-hole drainage for CSDH that is feasible to derive using national hospital data. Future work should explore how to estimate a minimally important clinical difference for DAOH and evaluate its utility as an outcome measure.

Background Chronic subdural hematoma (CSDH) is commonly treated by burr-hole drainage with subgaleal or subdural drain insertion, mostly based on surgeon’s preference. We analyzed the recurrence rate and clinical outcomes after burr-hole drainage for CSDH and subdural or subgaleal drain insertion in a single center, retrospective cohort study. Methods 700 cases of burr-hole drainage for CSDH between 2017 and 2022 were included. Subdural drain insertion was compared to subgaleal drain insertion. The primary outcome were the rates of recurrence and reoperation. The secondary outcomes consisted of morbidity, postoperative complications, and mortality. Results Baseline characteristics were comparable. The recurrence and reoperation rate after subdural drainage were respectively 15.3% (38/249) and 9.6% (24/249). The recurrence and reoperation rate after subgaleal drainage were respectively 13.4% (55/409) and 10.8% (44/409). There were no significant associations found in recurrence and reoperation rate between both drain insertions. No differences in morbidity, complication rate and mortality between drain insertion locations was found. Conclusion We found relative equipoise between subdural or subgaleal drain insertion concerning recurrence, reoperation rate or clinical outcome. A large multicenter randomized controlled trial could be designed to further assess the outcomes of subdural and subgaleal drain placement after burr-hole drainage for CSDH.

IntroductionThe main treatment of chronic subdural haematoma (CSDH) is neurosurgical evacuation with subsequent drainage. However, consensus on optimal drain modality and placement is lacking.AimTo examine whether 24-hour active subperiosteal drainage is non-inferior to 24-hour passive subdural drainage after a single burr hole evacuation of a symptomatic CSDH.Methods and analysisSUPERDURA is a multicentre randomised non-inferiority trial encompassing all neurosurgical units in Denmark. Adult patients with symptomatic CSDH admitted to a Danish neurosurgical unit for single burr hole evacuation will be screened for inclusion. Patients who are not able to give informed consent, and patients with recurrent CSDH, known cerebrospinal fluid abnormalities and other known brain pathologies will be excluded. Patients with bilateral CSDH will be registered as one case and treated similarly on both sides. Before surgical haematoma evacuation, patients will be randomised to 24-hour passive subdural drainage or 24-hour active subperiosteal drainage. The patients included and the two study statisticians will be blinded. The primary outcome is a composite outcome of 90-day mortality and symptomatic CSDH recurrence. Secondary outcomes are 90-day simplified modified Rankin score, 90-day serious adverse events and complications related to surgery or occurring during admission, including intracerebral haemorrhage due to misplaced drains, acute subdural haematoma, tension pneumocephalus, wound infection, drain seepage, subperiosteal haematoma, thromboembolic events, infections and seizures.A detailed statistical analysis plan is published separately. Sample size simulations of non-inferiority with a threshold of 7% increased relative risk show that a total of 354 participants will be required to demonstrate a relative risk reduction of recurrent CSDH and mortality of 30% for the cohort receiving active subperiosteal drainage given a stable power above 80% with an alpha of 5%. The study inclusion period is estimated to last 2 years.Ethics and disseminationEthics approval for the inclusion of competent patients has been obtained from the North Denmark Region Committee on Health Research Ethics. Results of the primary and secondary outcomes will be submitted for publication in an international peer-reviewed journal and presented at relevant neurosurgical meetings.Trial registration number at ethics committeeN-20240009, accepted 13 May 2024 and 13 December 2024.Trial registration numberNCT06621407.

Background Chronic subdural hematoma (cSDH) is a common intracranial hemorrhage in elderly patients and is associated with substantial postoperative recurrence rates. Tranexamic acid (TXA) has been proposed as an adjuvant therapy to reduce recurrence by targeting hyperfibrinolysis; however, its efficacy and impact on hematoma volume evolution remain controversial. Methods We performed a retrospective cohort study of adult patients who underwent burr-hole evacuation with subdural drainage for cSDH at a single neurosurgical center between 2012 and 2024. Patients receiving postoperative TXA within 48 h for at least 30 days were compared with patients treated surgically without TXA. Propensity score matching (1:1) was applied to balance baseline characteristics. The primary outcome was revision surgery for recurrent cSDH within 3 months. Secondary outcomes included postoperative hematoma volume evolution and all-cause mortality. Results After matching, 73 patients were included in each group with well-balanced baseline characteristics. Revision surgery within 90 days occurred less frequently in the TXA group compared with controls (8.2% vs. 19.2%; OR 0.40, 95% CI 0.14–1.12; p  = 0.042), although the confidence interval marginally crossed unity, indicating limited precision. Median time to revision was 8 days in the TXA group and 11 days in the control group. Mortality was numerically lower in the TXA group, with no deaths observed, compared with one death (1.4%) in the control group. Preoperative, postoperative, and one-month follow-up hematoma volumes were comparable between groups, and no significant difference in absolute volume reduction was detected. Conclusion Postoperative adjuvant TXA therapy after surgical evacuation of cSDH was associated with a lower rate of recurrence requiring revision surgery, without an observed increase in mortality; however, the confidence interval marginally crossed unity, and the findings should be regarded as hypothesis-generating. TXA did not significantly influence short-term hematoma volume reduction. Prospective randomized studies are needed to confirm these findings and define optimal dosing strategies.

Background Placement of a subdural drain after drainage of chronic subdural haematoma (CSDH) has been shown to reduce the rate of recurrence in several randomised controlled trials (RCT). The most recently published RCT was from Cambridge, UK, in 2009. Despite class I evidence for the use of subdural drains, it is unclear whether these results have been translated into clinical practice. In this clinical audit we review the use of subdural drains in our institution before and after the publication of the 2009 RCT results. Methods A longitudinal retrospective study was performed on all adults having burr holes for CSDH between January 2009 and January 2014. Case notes were analysed to determine subdural drain use, re-operation for CSDH recurrence and post-operative complications. The audit loop was closed with data collected from August 2015 to January 2016. Results Thirty-one per cent of patients had subdural drains placed at operation. Drain placement was associated with lower reoperation rates (8% vs. 17%, p = 0.021) without increasing complication rates. Drain usage doubled after publication of the Santarius et al. (2009) trial but we observed persisting and significant variability in drain utilisation by supervising consultants. The use of drains in the department increased from 35% to 75% of all cases after presentation of these results. Conclusions The use of subdural drains in our unit reduced recurrence rates following drainage of CSDH and reproduced the results of a 2009 clinical trial. Although the use of subdural drains doubled in the post-trial epoch, significant variability remains in practice. Clinical audit provided an effective tool necessary to drive the implementation of subdural drain placement in our unit.