Subperiosteal versus Subdural Drainage in Burr-Hole Trepanation for Chronic Subdural Hematomas: A Meta-Analysis

doi:10.21203/rs.3.rs-3103535/v1

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Subperiosteal versus Subdural Drainage in Burr-Hole Trepanation for Chronic Subdural Hematomas: A Meta-Analysis

https://doi.org/10.21203/rs.3.rs-3103535/v1

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Background

Chronic subdural hematoma (CSDH) is a common neurological disorder in older patients, and immediate outcomes of surgery for CSDH are satisfactory. However, the evidence for subperiosteal drainage (SPD) versus subdural drainage (SDD) in CSDH remains controversial. In this study, we aimed to assess the latest evidence on the use of SPD versus SDD in patients with CSDH who underwent burr hole evacuation.

Methods

We performed a systematic literature search on the use of SPD compared with that of SDD in patients with CSDH in PubMed, Web of Science, Embase, and Cochrane online databases from inception until December 2021. The inclusion and exclusion criteria were defined for eligible studies. A fixed-effects model was used when homogeneity was observed.

Results

A total of 1013 participants from six studies were included. There were no significant differences in the recurrence rate (odds ratios [OR], 0.87; 95% confidence interval [CI], 0.61–1.26; I2 = 0%; P = 0.47) or the mortality rate (P = 0.89) between the SPD and SDD groups. Additionally, various characteristics, including the rate of subsequent seizures (P = 0.74), sex distribution (P = 0.37), and favorable clinical outcome rates (OR, 1.13; 95% CI, 0.74–1.72; I2 = 0%; P = 0.58), were also similar between the two groups. Moreover, there was no significant difference in the effects of antithrombotic agents between the two groups (P = 0.12).

Conclusions

There were no differences in recurrence rates, sex distribution, postoperative mortality, seizures, favorable outcomes (modified Rankin scale score: 0–3), or effects of antithrombotic agents between the SPD and SDD groups. These findings suggest that both SPD and SDD are equally effective in treating patients with CSDH.

chronic subdural hematoma

meta-analysis

subperiosteal

subdural

drainage

burr hole

Chronic subdural hematoma (CSDH) is a frequently encountered condition in neurosurgery, predominantly in the elderly population. Its incidence stands at 58.0 per 100,000 individuals per year for those over the age of 65(1). Recent research indicates its origin lies in a complex biological process. The process involves interconnected mechanisms, including inflammation, membrane formation, angiogenesis, and fibrinolysis, all of which; together; can increase the volume of the CSDH (2).

Surgery is the standard treatment for CSDHs, with twist-drill craniotomy and burr-hole trephination being the most frequently employed surgical techniques (3). In addition, the use of an endoscope can aid in the treatment of organized and multiloculated CSDHs (4). Among the techniques mentioned, burr-hole drainage remains the most popular method for the surgical evacuation of CSDH (5). Concurrently, the use of subperiosteal drainage (also known as subglacial drainage) has gradually been applied in CSDH treatment (6). Several studies have investigated the outcomes of subperiosteal drain (SPD) versus subdural drain (SDD) following burr-hole trephination for CSDHs (6–13). Nevertheless, contrasting conclusions have been drawn regarding the two treatments.

In this study, we conducted a meta-analysis to evaluate the efficacy of SPD and SDD in patients with CSDH. We further compared the data from the two distinct surgeries to investigate any differential effects on CSDH.

2.1 Literature Search

We conducted a systematic search for qualifying studies in PubMed, Web of Science, Embase, and Cochrane online databases. The search terms used were “chronic subdural hematoma,” “bure hole,” and “randomized controlled trial” (RCT). We included written in English and published before December 2021 were included. The search was done by 2 investigators simultaneously and independently.

2.2 Inclusion and Exclusion Criteria

The inclusion criteria for our meta-analysis were as follows: diagnosis of CSDH, confirmed by computed tomography scans and/or magnetic resonance images before surgery; patients with CSDH who underwent SPD or SDD; comparative studies that reported one or more clinical outcomes of interest; and RCT.

The exclusion criteria were as follows: systematic reviews or case reports, only an abstract available, studies reporting irrelevant outcomes, or studies not written in English.

2.3 Data Extraction and Outcomes

Two authors independently evaluated the search results by reading the article titles, and two other authors independently reviewed the abstracts of the initially screened articles. The primary outcome measure was postoperative CSDH recurrence. The secondary outcomes were surgical complications (surgical infections and postoperative seizures), mortality within 6 months postoperatively, and favorable results with a modified Rankin scale (mRS) score of 0–3. Other related factors were also extracted, such as the names of the first authors, year of publication, country of publication, and the population characteristics included in the studies.

2.4 Study Quality Assessment

As all studies were RCTs, we used the Newcastle–Ottawa Quality Assessment Scale for RCT as our quality assessment tool. This validated scale evaluates RCTs based on three characteristics: selection of study groups, comparability between groups, and the outcome of interest.

2.5 Statistical Analyses

Data were processed using Review Manager 5.3 as supplied by the Cochrane Collaboration (Oxford, UK). Statistical analyses of dichotomous variables were performed using odds ratios (ORs) as summary statistics. Statistical significance was set at P < 0.05 or a 95% confidence interval (CI) of ORs not including 1. Effect sizes were expressed as (pooled) OR estimates. We interpreted the pooled data as heterogeneous if the probability value of the χ2 test was < 0.10.

3.1 Study Selection and Characteristics

The details of the search are presented in Fig. 1. We reviewed 329 potentially relevant articles on CSDH. A total of 163 records remained after the manual removal of duplicates. After screening the titles and abstracts, six studies involving 1013 participants were included in the final analysis (Table 1) (7–12). The qualitative methodological assessment of the included studies is shown in Fig. 2. A summary of the methodological quality is presented in Fig. 3.

Table 1

Baseline characteristics across studies
First Author	Year	Country	NOS
First Author	Year	Country	Selection				Comparability		Exposure			Score
Levin Häni	2019	Switzerland	*	*	*	*	*	*		*	*	8
Chandrasekaran Kaliaperumal	2012	Ireland		*	*	*	*	*		*	*	7
Maria Kamenova	2020	Basel	*	*	*	*	*	*		*	*	8
Katharina Lutz	2019	Switzerland	*	*	*	*	*	*		*	*	8
Kolakoth Pathoumthong	2021	Thailand		*	*	*	*	*		*	*	7
Jehuda Soleman	2019	Switzerland	*	*	*	*	*	*		*	*	8

NOS = Newcastle–Ottawa Scale.

For our comparisons, we utilized data from 964 patients across 5 studies to compare the recurrence rate. We derived postoperative mortality data from 922 patients in 4 studies, and favorable outcome data (mRS score 0–3) from 793 patients across 5 studies. To compare the postoperative effects of antithrombotic agents between SPD and SDD, we used data from 661 patients from 4 studies. Furthermore, we analyzed data from these 661 patients across 4 studies to ascertain whether SPD and SDD could lead to postoperative seizures. Finally, all 1013 patients were analyzed to investigate the effects of sex. We detected no heterogeneity in any of our efficacy or acceptability analyses.

3.2 Recurrence Rates

A total of 5 studies, including 964 patients, compared the recurrence rate between SPD and SDD. No significant difference in the recurrence rate was found between the two groups (OR, 0.87; 95% CI, 0.61–1.26; I² = 0%; P = 0.47) (Fig. 4A), and no publication bias was found based on the funnel plot (Fig. 4B).

3.3 Postoperative Mortality

All studies involving 1013 patients evaluated the postoperative mortality rate. In the studies by Chandrasekaran Kaliaperumal et al. (7) and Kolakoth et al. (10), there was no mortality throughout the entire study duration in either group. SDD was not associated with an increased risk of mortality in patients with CSDH compared with SPD (OR, 0.96; 95% CI, 0.55–1.67; I² = 0%; P = 0.89) (Fig. 5A). The funnel plot showed no publication bias (Fig. 5B).

3.4 Postoperative Seizures

All but two studies (9, 12) comprising 661 participants reported the rate of postoperative seizures. Patients in the SDD group had no significant risk of postoperative seizures compared with those in the SPD group (OR, 1.13; 95% CI, 0.55–2.31; I² = 0%; P = 0.74) (Fig. 6A). No publication bias was observed (Fig. 6B).

3.5 Sex

All studies, including 1013 patients, showed sex distribution in the SPD and SDD groups. The rate of sex was not significant between the two groups (OR, 1.13; 95% CI, 0.87–1.47; I² = 0%; P = 0.37) (Fig. 7).

3.6 Favorable Clinical Outcome Rates

Five studies, including 793 patients, reported favorable outcomes (mRS score: 0–3). The favorable clinical outcome rate was similar between the two groups (OR, 1.13; 95% CI, 0.74–1.72; I² = 0%; P = 0.58) (Fig. 8).

3.7 Effects of Antithrombotic Agents

We compared the effects of antithrombotic agents between the SPD and SDD groups. Four studies, including 661 patients, compared the efficacy of SPD and SDD in terms of the use of antithrombotic agents and their postoperative effects. Although the use of antiplatelets tended to be associated with a lower reoperation rate of CSDH, no significant difference was found between the two groups (OR, 0.78; 95% CI, 0.57–1.07; I² = 0%; P = 0.12) (Fig. 9A). There was no obvious asymmetry in the funnel plot (Fig. 9B).

In this meta-analysis, we compared two surgical methods for CSDH, finding no significant differences between SPD and SDD in terms of recurrence, sex distribution, favorable postoperative outcomes (mRS scores: 0–3), mortality, seizures, and effects of antithrombotic agents.

Surgery continues to be the primary treatment option for CSDH (13), and surgical management of CSDH is well-established. However, the recurrence rate of CSDH remains notably high (2.3–38.7%) (14). Jehuda et al. (15) conducted a survey on the worldwide use of drains for CSDH and concluded that both SPD and SDD could reduce recurrence and complication rates. As interest grows in understanding the efficacy of SPD and SDD, studies vary: some found SPD associated with lower CSDH recurrence than SDD (8, 16), while others found no difference in recurrence rates (7, 11, 17, 18) – a finding echoed in our meta-analysis. Despite including only 5 RCTs in this meta-analysis, we found low heterogeneity amongst the included studies. Further high-powered RCTs comparing subdural and subperiosteal drains will be valuable to confirm these conclusions.

Postoperative complications following burr hole drainage for CSDH, such as seizures, surgical infections, and intracerebral hemorrhage, occur at rates of 3–28% (19). Posttraumatic epilepsy may also develop due to brain injury (20). Our study found no significant difference in postoperative seizure rates between the SPD and SDD groups, despite a higher potential for brain parenchymal irritation and seizures in the SDD group. Similarly, we found no significant mortality differences between patients treated with SPD or SDD. Given that CSDH often affects older adults, it's plausible that deterioration of their overall health, rather than brain surgery and its complications, may lead to postoperative death in some patients with complications (21, 22).

Sex distribution did not differ significantly between the SPD and SDD groups, nor did it influence the efficacy of the two procedures. We found no significant difference in favorable outcome rates (mRS score, 0–3) between the SPD and SDD groups, aligning with some studies (8, 10–12). However, Kaliaperumal et al. (7) found that patients treated with SPD had better pre- and postoperative mRS scores than those treated with SDD, possibly due to the superior preoperative average mRS score in the SPD group. Lastly, we found no significant differences in the postoperative effects of antithrombotic agents between the SPD and SDD groups, corroborating Kaliaperumal et al.'s small prospective randomized study (7) suggesting that preoperative anticoagulant use did not affect the efficacy of the drainage system.

Our study has limitations. The number of studies included was small, underlining the need for more RCTs. Additionally, the small sample sizes in two studies (< 40 cases in each group) may have influenced the results. Moreover, differing diagnostic criteria and techniques among various hospitals could result in disparate results within the studies we analyzed.

Our study revealed no significant differences in the recurrence rates, sex distribution, postoperative mortality, seizure incidence, favorable outcomes (indicated by mRS scores: 0–3), or use of antithrombotic agents between the SPD and SDD groups. These findings suggest that both SPD and SDD are equally effective in treating patients with CSDH. Additional RCTs or other established experimental designs are required to confirm our present conclusion. To reinforce our current conclusions, further randomized controlled trials or other rigorous experimental designs are necessary.

Chronic subdural hematoma (CSDH); subperiosteal drainage (SPD); subdural drainage (SDD); randomized controlled trial (RCT); modified Rankin scale (mRS); confidence interval (CI)

Data Availability Statement

The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding authors.

Conflict of interest

The authors declare that they have no conflict of interest.

Authors’ contribution

GJS and XJH proposed and designed the study. GJS acquired data and drafted the manuscript. DZ, JNW, and YHD extracted and interpreted the available data and performed extensive research on this topic. XJH and LGL critically revised the manuscript. CWW performed the statistical analyses. All the authors contributed to the writing of the manuscript.

Ethical approval

For this type of study, formal consent is not required.

Informed consent

Not applicable.

Funding

Not applicable.

Acknowledgments

We would like to thank Editage (www.editage.cn) for English language editing.

1Iliescu IA. Current diagnosis and treatment of chronic subdural haematomas. J Med Life. 2015;8:278–84.
Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: Inflammation, angiogenesis, and implications for pharmacotherapy. J Neuroinflammation. 2017;14:108. 10.1186/s12974-017-0881-y.
Lee KS. How to treat chronic subdural hematoma? Past and now. J Korean Neurosurg Soc. 2019;62:144–52. 10.3340/jkns.2018.0156.
Yadav YR, Parihar V, Namdev H, Bajaj J. "Chronic subdural hematoma " Asian J Neurosurg. 2016;11:330–42. 10.4103/1793-5482.145102.
Jehuda S, Maria K, Katharina L, et al. Drain insertion in chronic subdural hematoma: An international survey of practice. World Neurosurg. 2017;104:528–36. 10.1016/j.wneu.2017.04.134.
Huaqiang D, Shengjie L, Xingyun Q, et al. Subperiosteal versus subdural Drain after Burr Hole Drainage for Chronic subdural hematomas: A Systematic Review and Meta-Analysis. World Neurosurg. 2020;136:90–100. 10.1016/j.wneu.2019.12.180.
Gazzeri R, Galarza M, Neroni M et al. "Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma." Acta Neurochir (Wien), 2007, 149: 487 – 93; discussion 493. doi: 10.1007/s00701-007-1139-8.
Chandrasekaran K, Ayman K, Fenton E, et al. A prospective randomised study to compare the utility and outcomes of subdural and subperiosteal drains for the treatment of chronic subdural haematoma. Acta Neurochir (Wien). 2012;154:2083–8. 10.1007/s00701-012-1483-1. discussion 2088–9.
Soleman J, Lutz K, Schaedelin S, Kamenova M, Guzman R, Mariani L et al. "Subperiosteal vs subdural drain after burr-hole drainage of chronic subdural hematoma: A randomized clinical trial (cSDH-Drain-Trial)." Neurosurgery, 2019, 85:E825–34. doi: 10.1093/neuros/nyz095.
Katharina L, Maria K, Sabine S, et al. Time to and possible risk factors for recurrence after burr-hole drainage of chronic subdural hematoma: A subanalysis of the cSDH-drain randomized controlled trial. World Neurosurg. 2019;132:e283–9. 10.1016/j.wneu.2019.08.175.
Kolakoth P, Chumpon J. Comparative study of subdural drain (SDD) versus sub periosteal drain (SPD) in treating the patient with chronic subdural hematoma (CSDH). Surg Neurol Int. 2021;12:421. 10.25259/sni_592_2021.
Levin H, Sonja V, Mattia B, et al. Subdural versus subglacial drainage for chronic subdural hematomas: A post hoc analysis of the TOSCAN trial. J Neurol Surg. 2019. 10.3171/2019.5.jns19858.
Maria K, Katharina L, Sabine S, et al. Subperiosteal versus subdural Drain after Burr-hole Drainage under Blood Thinners: A subanalysis of the cSDH-Drain RCT. World Neurosurg. 2020;139:e113–20. 10.1016/j.wneu.2020.03.134.
James F, Wuyang Y, Judy H. Updates in chronic subdural hematoma: Epidemiology, etiology, pathogenesis, treatment, and outcome. World Neurosurg. 2020;141:339–45. 10.1016/j.wneu.2020.06.140.
Motiei-Langroudi R, Stippler M, Shi S, Adeeb N, Gupta R, Griessenauer CJ, et al. Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation. J Neurosurg. 2018;129:1143–50. 10.3171/2017.6.JNS17130.
Bellut D, Woernle CM, Burkhardt JK, Kockro RA, Bertalanffy H, Krayenbühl N. Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas. World Neurosurg. 2012;77:111–8. 10.1016/j.wneu.2011.05.036.
Wei CAN, Sii HA, Rahman NAA, et al. Subperiosteal Drainage versus subdural drainage in the management of Chronic subdural Hematoma (A Comparative Study). Malays J Med Sci. 2017;24:21–30. 10.21315/mjms2017.24.1.3.
Oral S, Borklu RE, Kucuk A, Ulutabanca H, Selcuklu A. Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma. North Clin Istanb. 2015;2:115–21. 10.14744/nci.2015.06977.
Rohde V, Graf G, Hassler W. Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: A retrospective analysis of 376 patients. Neurosurg Rev. 2002;25:89–94. 10.1007/s101430100182.
Lucke-Wold BP, Nguyen L, Turner RC, Logsdon AF, Chen YW, Smith KE et al. "Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure." Seizure, 2015, 33:13–23. doi: 10.1016/j.seizure.2015.10.002.
De Bonis P, Simone O, Lorenzo M, Cavallo MA, Santantonio M, Trevisi G, et al. Chronic subdural hematoma in patients aged 80 years and older: A two-centre study. Clin Neurol Neurosurg. 2018;170:88–92. 10.1016/j.clineuro.2018.05.002.
Ou Y, Dong J, Wu L, Xu L, Wang L, Liu B, et al. A comparative study of chronic subdural hematoma in three age ranges: Below. 40 Years, 41–79 Years, and 80 Years and Older. Clin Neurol Neurosurg. 2019;178:63–9. 10.1016/j.clineuro.2019.01.018.

No competing interests reported.

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Subperiosteal versus Subdural Drainage in Burr-Hole Trepanation for Chronic Subdural Hematomas: A Meta-Analysis

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

1 Introduction

2 Materials and Methods

2.1 Literature Search

2.2 Inclusion and Exclusion Criteria

2.3 Data Extraction and Outcomes

2.4 Study Quality Assessment

2.5 Statistical Analyses

3 Results

3.1 Study Selection and Characteristics

3.2 Recurrence Rates

3.3 Postoperative Mortality

3.4 Postoperative Seizures

3.5 Sex

3.6 Favorable Clinical Outcome Rates

3.7 Effects of Antithrombotic Agents

4 Discussion

5 Conclusions

Abbreviations

Declarations

References

Additional Declarations

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