Introduction: In symptomatic chronic subdural hematomas (cSDH) necessitating neurosurgical evacuation, drainage via a minimally invasive twist drill craniostomy performed at bedside in the ICU has been proposed as an alternative to standard burr hole evacuation performed in the OR.
Methods: We retrospectively analyzed the single-institution, single-surgeon experience of 49 consecutive cSDH evacuation procedures. Patients presenting with symptomatic cSDH were initially assigned to either twist drill craniostomy (at bedside in ICU, under conscious sedation) or burr hole evacuation (in OR) by the attending neurosurgeon. All patients had a large-bore subdural catheter left in place during clinical and radiographic inpatient followup.
Results: 43 patients underwent 18 bedside and 31 OR procedures. At baseline, the bedside and OR groups were similar in age (79.8 vs. 81.9 years), gender, and radiographic characteristics of cSDH composition, thickness, and mass effect. Complications were of similar incidence, with need for 2 repeat procedures in the bedside group and 3 reoperations in the OR group due to reaccumulation. All other patients had a satisfactory clinical-radiographic result. The incidence of postoperative pneumocephalus (Grade 2 or higher) was lower after bedside procedures (28% vs. 48%, p=0.03). No patients initially treated at bedside required conversion to surgery, although 2 patients treated with burr holes in the OR later underwent bedside drainage. No mortalities. Postoperative recovery was enhanced in the bedside group, with more patients discharged to home (75% vs. 55%, p=0.01) as well as trends toward shorter mean length of stay in ICU (3.2 vs. 4.1 days) and hospital (6.8 vs. 8.5 days).
Conclusions: Minimally invasive bedside drainage of cSDH in the ICU represents a viable alternative to standard burr hole surgery. Whereas the bedside and OR groups had equivalent clinical-radiographic outcomes, elderly patients undergoing bedside drainage showed evidence of better postoperative recovery and reduced healthcare resource utilization.
Patient Care: A greater appreciation for the technique of subdural hematoma drainage via twist drill at bedside in the ICU may lead to reduced cost, better patient outcomes in terms of length-of-stay, and expanded treatment options for patients who are too elderly or infirm to undergo general anesthesia in the OR.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Compare the surgical techniques of burr hole evacuation of chronic subdural hematoma in the OR versus the minimally invasive approach via craniostomy in the ICU;
2) Discuss the advantages and disadvantages of minimally invasive subdural hematoma drainage, in terms of resource utilization, patient outcome, and patient eligibility;
3) Identify an effective set of treatment options for neurosurgical patients presenting with chronic subdural hematoma;
4) Discuss future directions of clinical research on techniques for draining subdural hematoma, including the need for additional prospective data.
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