Subdural versus subgaleal drainage for chronic subdural hematomas: a post hoc analysis of the TOSCAN trial.

Häni, Levin; Vulcu, Sonja; Branca, Mattia; Fung, Christian; Z'Graggen, Werner Josef; Murek, Michael; Raabe, Andreas; Beck, Jürgen; Schucht, Philippe (2019). Subdural versus subgaleal drainage for chronic subdural hematomas: a post hoc analysis of the TOSCAN trial. (In Press). Journal of neurosurgery, pp. 1-9. American Association of Neurological Surgeons 10.3171/2019.5.JNS19858

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OBJECTIVE The use of subdural drains after surgical evacuation of chronic subdural hematoma (CSH) decreases the risk of recurrence and has become the standard of care. Halfway through the controlled, randomized TOSCAN (Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma) trial, the authors' institutional guidelines changed to recommend subgaleal instead of subdural drainage. The authors report a post hoc analysis on the influence of drain location in patients participating in the TOSCAN trial. METHODS The study involved 361 patients enrolled in the TOSCAN trial. The patients were stratified according to whether they received surgery before (cohort A) or after (cohort B) the change in institutional protocol. An intention-to-treat analysis was performed with surgery for recurrence as the primary endpoint. Secondary endpoints were outcome-based on modified Rankin Scale scores, seizures, infections, parenchymal brain injuries, and hematoma diameter. RESULTS Of the 361 patients included in the analysis, 214 were stratified into cohort A (subdural drainage recommended), while 147 were stratified into cohort B (subgaleal drainage recommended). There was a 31.78% rate of crossover from the subdural to the subgaleal drainage insertion site due to technical or anatomical difficulties. No differences in the rates of reoperation (21.5% [cohort A] vs 25.17% [cohort B], OR 0.81, 95% CI 0.50-1.34, p = 0.415), infections (0.47% [cohort A] vs 2.04% [cohort B], OR 0.23, 95% CI 0.02-2.19, p = 0.199), seizures (3.27% [cohort A] vs 2.72% [cohort B], OR 1.21, 95% CI 0.35-4.21, p = 0.765), or favorable outcomes (modified Rankin Scale score 0-3) at 1 and 6 months (91.26% [cohort A] vs 96.43% [cohort B], OR 0.39, 95% CI 0.14-1.07, p = 0.067; 89.90% [cohort A] vs 91.55% [cohort B], OR 0.82, 95% CI 0.39-1.73, p = 0.605) were noted between the two cohorts. Postoperatively, patients in cohort A had more frequent parenchymal brain tissue injuries (2.8% vs 0%, p = 0.041). Postoperative absolute and relative hematoma reduction was similar irrespective of the location of the drain. CONCLUSIONS Subgaleal rather than subdural placement of the drain did not increase the risk for reoperation for recurrence of CSHs, nor did it have a negative impact on clinical or radiological outcome. The intention to place a subdural drain was associated with a higher rate of parenchymal injuries.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurosurgery
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology
04 Faculty of Medicine > Pre-clinic Human Medicine > CTU Bern

UniBE Contributor:

Häni, Levin; Vulcu, Sonja; Branca, Mattia; Z'Graggen, Werner Josef; Murek, Michael Konrad; Raabe, Andreas; Beck, Jürgen and Schucht, Philippe

Subjects:

600 Technology > 610 Medicine & health

ISSN:

0022-3085

Publisher:

American Association of Neurological Surgeons

Language:

English

Submitter:

Beatrice Minder Wyssmann

Date Deposited:

01 Nov 2019 16:26

Last Modified:

04 Nov 2019 09:33

Publisher DOI:

10.3171/2019.5.JNS19858

PubMed ID:

31470410

Additional Information:

Häni and Vulcu contributed equally to this work

Uncontrolled Keywords:

CI = confidence interval CSH = chronic subdural hematoma NIHSS = NIH Stroke Scale OR = odds ratio TOSCAN = Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma burr hole trepanation mRS = modified Rankin Scale subdural drainage subgaleal drainage surgical management symptomatic subdural hematoma vascular disorders

BORIS DOI:

10.7892/boris.134553

URI:

https://boris.unibe.ch/id/eprint/134553

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