|Year : 2014 | Volume
| Issue : 3 | Page : 173-175
Chronic subdural hematoma: Influence of head position (head low/supine) postoperatively on recurrence rate after burr hole craniotomy
Tanay Upendra Sholapurkar, Shambhulingappa Shrishal Mahantashetti, Rajesh Yashwant Shenoy, Raviraj Shambhajirao Ghorpade, Praful Suresh Maste
Department of Neurosurgery, KLES Hospital, Belgaum, Karnataka, India
|Date of Web Publication||19-Sep-2014|
Tanay Upendra Sholapurkar
Opd No 34, second floor, Neurosurgery Opd, Kles Hospital, Nehru nagar, belgaum, 590010
Source of Support: None, Conflict of Interest: None
Introduction and Objective: Chronic subdural hematoma is the most common traumatic intra-cranial hemorrhage in elderly. It has serious morbidity and mortality, but good surgical prognosis. Burr hole craniotomy is the most common form of treatment for chronic subdural hematoma. However, there have been very few studies to see the postoperative influence of head position (head low/supine) on recurrence of chronic subdural hematoma. The aim of this study is to compare recurrence rates between patients given head low position postoperatively versus supine position after burr hole craniotomy. Materials and Methods: During the period of months from August 2011 to August 2013, 78 patients of chronic subdural hematoma treated with burr hole craniotomy were included. Pre- and post-operative computed tomography scan\magnetic resonance imaging scan were used for radiological evaluation. After surgical intervention, the preference of head position (supine/head low) of the patient was decided by treating neurosurgeon. Head low position was kept for 3 days. Supine position was given for the rest of the patients. All patients were followed-up for at least 1 month after discharge. Results: Of the 78 patients, 16 patients were given head low position, whereas 62 were given supine position. The overall recurrence rate was 7.69% (6 out of 78) in our study. One of 16 patients (6.25%) given head low position recurred, whereas 5 of 62 patients (8.06%) who were given supine position recurred. Statistically (P > 0.05) postoperative recurrence rate in both groups were same. Conclusion: Results of our study indicate that patients who were given head low position had same recurrence rate as those who were given supine position. Hence, postoperatively position of the head does not influence the recurrence rates.
Keywords: Burr hole, chronic subdural hematoma, head low, recurrence
|How to cite this article:|
Sholapurkar TU, Mahantashetti SS, Shenoy RY, Ghorpade RS, Maste PS. Chronic subdural hematoma: Influence of head position (head low/supine) postoperatively on recurrence rate after burr hole craniotomy. J Sci Soc 2014;41:173-5
|How to cite this URL:|
Sholapurkar TU, Mahantashetti SS, Shenoy RY, Ghorpade RS, Maste PS. Chronic subdural hematoma: Influence of head position (head low/supine) postoperatively on recurrence rate after burr hole craniotomy. J Sci Soc [serial online] 2014 [cited 2020 Mar 28];41:173-5. Available from: http://www.jscisociety.com/text.asp?2014/41/3/173/141209
| Introduction|| |
Chronic subdural hematoma (CSDH) is one of the most common types of traumatic intracranial hematoma, and often occurs in the elderly. ,,,, Surgical treatment has been widely accepted as the most effective way to manage CSDH. Burr hole craniotomy is now widely accepted as the standard form of surgical intervention for chronic subdural hematoma. ,,, Recurrence in chronic subdural hematoma is known and ranges from 9.2% to 26.5% after surgical evacuation. , There are many studies about numerous factors, potentially associated with recurrences after the surgical procedures, which are still highly controversial. ,, Influence of head position postoperatively on recurrence rates rarely been evaluated. In this study, we compared the recurrence rates between patients given head low position for 3 days postoperatively versus patients given supine position.
| Materials and methods|| |
During the period of months from August 2011 to August 2013, 78 consecutive patients (69 men and 9 women) with CSDH who underwent burr hole craniotomy at our hospital were included in the study. Three additional patients treated with craniotomy were excluded. CSDH was defined as the presence of a typical neo-membrane, liquefied blood within the hematoma cavity, and at least 3 weeks had passed from the event of head trauma. Diagnosis was confirmed by computed tomography (CT) scans and/or magnetic resonance images in all patients. Operations were performed under either general or local anesthesia. All patients underwent surgical procedures of one or two burr holes over the area of maximal hematoma width and flushing of hematoma with irrigating fluid until returning fluid was clear. Postoperatively 16 patients were given head low position for 3 days according to treating neurosurgeons preference and rest 62 were given supine position. Postoperative CT scan was done at an interval of one month after follow-up. Clinical and/or radiological criteria were used for evaluation of CSDH recurrence. The clinical criteria for recurrence included a change in mental status, worsening of the preexisting neurological deficit and new onset or aggravation of headache and the radiological criteria were the CT scans during the follow-up period postsurgically, which revealed an increased subdural collection and/or the brain parenchyma being compressed.
Statistical analysis was assessed by using the Fisher's test. Throughout the analysis, a P < 0.05 was considered as significant.
| Results|| |
There were a total of 78 patients, 69 men (88.46%, median age 59.75 years) and 9 women (11.5%, median age 62.44) in the study, ranging in age from 19 to 88 years (median age, 60). The demographic characteristics and clinical findings are shown in [Table 1].
|Table 1: Result: Infl uence of head position on recurrence of chronic subdural haematoma|
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The mean GCS at admission was 12.94 ± 3.2. 16 patients were given head low position (20.5%, median age 58.62 ± 17.25 years) and 62 patients were given supine position (79.48%, median age 60.43 ± 15.47 years). The patients were followed-up for at least 1 month after discharge. Among 78 operated patients, 6 patients were found to have a recurrence. In 16 patients who were given head low position 1 had a recurrence and in 62 who were given supine position 5 had recurrence. Of the total 78 patients, 26 were on the right side in frontotemporoparietal region, 33 were on the left side and 19 were bilateral. Out of the 6 recurrences 2 were right, 2 were left and 2 were bilateral.
Head low versus supine position
As mentioned above, 6 patients experienced postoperative recurrences; all were men in this study and ranging in age from 42 to 72 years (median age, 61.5 years). One patient in head-low group had a bilateral CSDH and recurrence was noted on the right side. The overall postoperative recurrence rate was 7.6%. The recurrence rate in patients given head low position was 6.25% (n = 1) and in the supine position was 8.06% (n = 5), respectively. Patients with supine position had a higher rate of recurrence than those with head low position. However, the position of head postoperatively, as a risk factor of CSDH recurrence was not statistically significantly associated with postoperative recurrence rate (P > 0.05).
| Discussion|| |
Chronic subdural hematomas mostly occurs in older patients by a relatively light trauma and usually at least 3 weeks passed from the event of trauma unnoticed. CSDH is considered to be a benign disease of the elderly.  The annual incidence of CSDH has been steadily increasing because the lifespan of the older population is increasing owing to the modern medical technology. The incidence is 13.1 cases per 100,000 inhabitants. Older age predisposes to the development of CSDH in a multifaceted fashion. Older patients suffer falls more often, treatment with anticoagulative medications is frequent, the risk for concomitant bleeding rises with age and finally, brain atrophy is a physiologic phenomenon in advanced age. 
Many risk factors for recurrences of CSDH have been reported previously, including age, history of trauma, bleeding tendency, brain atrophy, alcohol abuse, bilateral CSDHs, higher hematoma density, postoperative air accumulation, and some technical aspects of surgery. However, the results reported have sometimes been inconsistent.
Patient posture in the early days after surgery was also thought to influence the rate of recurrence. In the first prospective study, no difference was found with regard to recurrence and outcome.  A recent randomized controlled trial, however, found an increased incidence of CSDH recurrence when patients did not maintain a flat position in the first 3 days after surgery. Hence, in the present study, influence of head low position versus supine position postoperatively was studied for recurrence rates. Head low position postoperatively were given to the patients considering the gravity aiding brain to resurface and obliterate the increased subdural space thus anticipating to reduce the recurrence rates.
Some authors have regarded older age is one of the risk factors of CSDH recurrence, while other do not agree.  The results in our study were consistent with the agreement group. The age group of patients with CSDH in this study ranged from 19 to 88 years with a mean age being 60 years. Number of patients over the age of 50 years were 59.
In older publications, at least 70-80% of patients with CSDH were male. Newer studies describe a male-to-female ratio was 3:2.  In our study, 69 out of 78 (88.5%) were male.
Incidentally, in our study 42 patients out of 78 (53.84%) were found to have B Rh+ blood group. However, the influence of any specific blood group on occurrence of CSDH is not known. The frequency of B Rh+ blood group in general population is approximately 9%. Considering this, percentage of patients with CSDH having B Rh+ blood was significantly higher.
In our study, the overall postoperative recurrence rate was 7.6%. The recurrence rate in patients given head low position was 6.25% (n = 1) and in supine position was 8.06% (n = 5) respectively. Patients with supine position had a higher rate of recurrence than those with head low position. The present study was a nonrandomized, retrospective study, and thus is potentially subject to sources of bias and variation. Further investigations with larger sample size, quantitative controlled prospective study are required to assess the role of influence of head position postoperatively on recurrence of CSDH.
| Conclusion|| |
Results of our study indicate that patients who were given head low position had same recurrence rate as those who were given supine position. Hence, postoperatively position of head does not influence the recurrence rates.
| References|| |
|1.||McKissock W, Richardson A, Bloom W. Subdural haematoma: A review of 389 cases. Lancet 1960;275:1365-9. |
|2.||Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: Evidence based review. J Neurol Neurosurg Psychiatry 2003;74:937-43. |
|3.||Krauss JK, Marshall LF, Weigel R. Medical and surgical management of chronic subdural hematomas. Youmans Neurological Surgery. 6 th ed. 2011;1:535-43. |
|4.||Ernestus RI, Beldzinski P, Lanfermann H, Klug N. Chronic subdural hematoma: Surgical treatment and outcome in 104 patients. Surg Neurol 1997;48:220-5. |
|5.||Jeong CA, Kim TW, Park KH, Chi MP, Kim JO, Kim JC. Retrospective analysis of reoperated patients after chronic subdural hematoma surgery. J Korean Neurosurg Soc 2005;38:116-20. |
|6.||Lind CR, Lind CJ, Mee EW. Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains. J Neurosurg 2003;99:44-6. |
|7.||Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: A national survey and literature review. Can J Neurol Sci 2005;32:501-6. |
|8.||Krupp WF, Jans PJ. Treatment of chronic subdural haematoma with burr-hole craniostomy and closed drainage. Br J Neurosurg 1995;9:619-27. |
|9.||Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: A questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 2008;22:529-34. |
|10.||Kang MS, Koh HS, Kwon HJ, Choi SW, Kim SH, Youm JY. Factors influencing recurrent chronic subdural hematoma after surgery. J Korean Neurosurg Soc 2007;41:11-5. |
|11.||Nakaguchi H, Tanishima T, Yoshimasu N. Relationship between drainage catheter location and postoperative recurrence of chronic subdural hematoma after burr-hole irrigation and closed-system drainage. J Neurosurg 2000;93:791-5. |
|12.||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. |
|13.||Stanisic M, Lund-Johansen M, Mahesparan R. Treatment of chronic subdural hematoma by burr-hole craniostomy in adults: Influence of some factors on postoperative recurrence. Acta Neurochir (Wien) 2005;147:1249-56. |