Department of Neurosurgery, Heinrich-Heine-Universität, Düsseldorf, Germany.
Acta Neurochir (Wien). 2012 Jun;154(6):1063-7; discussion 1068. doi: 10.1007/s00701-012-1334-0. Epub 2012 Apr 4.
Burr-hole drainage has become the accepted treatment of choice for chronic subdural haematoma (cSDH), although still burdened with a major recurrence rate. The current analysis was initiated to determine management-related risk factors for recurrence, i.e. postoperative low-molecular-weight heparin thromboprophylaxis, and the importance of rinsing the subdural space.
Two-hundred and forty-seven patients with computerised tomography (CT) defined symptomatic cSDH were managed by two burr-hole trepanations and drainage between January 2005 and November 2008. Postoperative thromboprophylaxis with 40 mg enoxaparine daily was given only during the first half of the study period. For the current analysis the amount of rinsing fluid, postoperative low-dose thromboprophylaxis, as well as age and gender, bilaterality, preoperative and postoperative blood coagulation studies, platelet counts and decrease of subdural fluid on early postoperative CT, were recorded and correlated with recurrence. Statistical calculation was done by univariate and multivariate analysis.
A total of 62 of 247 patients needed revision surgery for recurrence (25.1 %). Recurrence rates were significantly lower in the patients treated without postoperative enoxaparine (18.84 %) than in the group with postoperative low-dose enoxaparine thromboprophylaxis (32.11 %) and enoxaparine was administered in a higher proportion of the patients suffering recurrence (P = 0.013). A median intraoperative irrigation volume of 863 ml saline was used in the patients suffering recurrence and 1,500 ml in patients without recurrence (P < 0.001). The median age was slightly higher in the patients suffering from recurrence. Male gender predominated in both groups but was slightly more pronounced in the recurrence group. Preoperative and postoperative platelet counts and plasmatic coagulation indices did not differ significantly between the groups. Relative residual subdural fluid collection on early postoperative CT remained larger in patients finally suffering recurrence (P = 0.03). Multivariate analysis confirmed a small amount of rinsing fluid, male gender and the use of enoxaparine as the most important risk factors for recurrence, although that latter factor did not reach statistical significance in the multivariate analysis.
The investigation provides evidence that copious intraoperative irrigation and avoidance of postoperative low-molecular-weight heparin thromboprophylaxis may reduce the recurrence rate of cSDH.
颅骨钻孔引流术已成为慢性硬脑膜下血肿（cSDH）的首选治疗方法，尽管复发率仍然很高。目前的分析旨在确定与管理相关的复发风险因素，即术后低分子肝素血栓预防，以及冲洗硬脑膜下腔的重要性。
2005 年 1 月至 2008 年 11 月，对 247 例 CT 定义的有症状 cSDH 患者进行了两次颅骨钻孔和引流。在研究的前半段，仅给予 40mg 依诺肝素每日一次的术后血栓预防。目前的分析记录了冲洗液量、术后低剂量血栓预防、年龄和性别、双侧性、术前和术后凝血研究、血小板计数以及术后早期 CT 上硬脑膜下积液减少的情况，并与复发相关。通过单变量和多变量分析进行统计学计算。
共有 247 例患者中有 62 例因复发需要再次手术（25.1%）。未接受术后依诺肝素治疗的患者（18.84%）复发率明显低于接受术后低剂量依诺肝素血栓预防的患者（32.11%），且在复发患者中依诺肝素的使用率更高（P=0.013）。在复发患者中使用的中位数为 863ml 生理盐水，而在无复发患者中使用的中位数为 1500ml（P<0.001）。复发患者的中位年龄稍高。两组均以男性为主，但在复发组中更为明显。两组患者的术前和术后血小板计数以及血浆凝血指数无显著差异。术后早期 CT 上相对残余硬脑膜下积液积聚在最终复发的患者中仍然更大（P=0.03）。多变量分析证实，冲洗液量少、男性和使用依诺肝素是复发的最重要危险因素，尽管后者在多变量分析中未达到统计学意义。
该研究提供的证据表明，术中大量冲洗和避免术后低分子肝素血栓预防可能会降低 cSDH 的复发率。
