Weigel R, Schmiedek P, Krauss J K
Department of Neurosurgery, University Hospital, Klinikum Mannheim, Mannheim, Germany.
J Neurol Neurosurg Psychiatry. 2003 Jul;74(7):937-43. doi: 10.1136/jnnp.74.7.937.
To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria.
A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty.
48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation).
The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.
根据循证医学标准评估当代神经外科治疗慢性硬膜下血肿的手术治疗方案的效果。
基于1981年至2001年10月期间的Medline搜索进行综述，使用“硬膜下血肿”和“硬膜下血肿与慢性”等短语。入选评估的文章至少有10例患者，且失访患者少于10%。根据美国神经病学学会的标准，文章被分为三类证据。不同治疗方案的推荐强度来自于由此产生的确定性程度。
共审查了48篇出版物。没有文章提供I类证据。6篇文章符合II类证据标准，其余文章提供III类证据。结果评估表明，钻孔引流术和骨孔开颅术比开颅手术更安全；骨孔开颅术和开颅手术是最有效的手术；骨孔开颅术的治愈率与并发症发生率之比最佳（C类推荐）。冲洗可降低钻孔引流术的复发风险，且不会增加感染风险（C类推荐）。引流可降低骨孔开颅术的复发风险，引流管置于额部可降低复发风险（B类推荐）。引流可降低钻孔引流术的复发风险，使用引流管不会增加感染风险（C类推荐）。骨孔开颅术在治疗复发性血肿方面似乎比钻孔引流术更有效，开颅手术应被视为复发性血肿的最后选择治疗方法（C类推荐）。
当代神经外科治疗慢性硬膜下血肿使用的三种主要技术——钻孔引流术、骨孔开颅术和开颅手术——在发病率、死亡率、复发率和治愈率方面具有不同的特点。钻孔引流术和骨孔开颅术可被视为一线治疗方法，而开颅手术可作为二线治疗方法。数据的累积总结表明，总体而言，慢性硬膜下血肿的术后结果在过去20年中并未显著改善。
