Use of Drains Versus No Drains After Burr-Hole Evacuation of Chronic Subdural Hematoma

  • Dr. Liaqat Mahmood Awan
  • Dr Ejaz Hussain Wadd Lahore General Hospital, Lahore
  • Dr. Asif Shabir Lahore General Hospital, Lahore
  • Dr. Khawar Anwar Lahore General Hospital, Lahore
Keywords: Chronic Subdural Hematoma, Burr-hole craniostomy, drain, recurrence


Objectives: To compare the recurrence of chronic subdural hematoma after burr hole evacuation with and without use of subdural drain.

Study Design: It was multicenter randomized control trial.

Setting: Department of Neurosurgery, SKBZ/CMH Muzaffarabad, Department of Neurosurgery, Lahore General Hospital Lahore.

Duration: This study was conducted between June 2017 to December 2017. Inclusion Criteria: Male and female 18-80 years and chronic subdural Hematoma with midline shift of more than 5mm on CT scan.

Exclusion Criteria: Bilateral chronic subdural hematoma on CT scan, recurrent CSDH, patients with CSF shunt in-situ, patient with bleeding disorders (INR > 2.5, BT > 7 min, platelet count < 60000) or on anticoagulant drugs, patients with severe systemic ailment like renal failure (Serum Creatinine > 2.5), chronic liver disease (ultrasound shows liver cirrhosis and splenomegaly) and uncontrolled diabetes (BSF > 126) and known ischemic heart disease were excluded from this study.

Materials and Methods: In this study, 80 patients were included and randomly divided into two equal groups. Patient fulfilling the inclusion criteria were included in the study through the emergency and outdoor. All Patients were prepared for the surgery and informed consent was taken from all patients. All patients were treated in exactly the same way as per standard ward routine practice except that the treatment option (whether to use the drain or not) was decided through randomization; Group A with drain and Group B without drain. All patients were discharged at 3rd post op day and followed for six months.

Results: There were only 16 (20%) patients in which recurrence occurred. Out of these 16 patients 4 (25%) belong to drain group while 12 (75%) belong to without drain group. While in 64 (80%) patients no recurrence was observed [group A: 36 (56.25%) vs. group B: 28 (43.75%)]. The difference between both groups was insignificant, (p-value = 0.235).

Conclusion: It was concluded form the results of this study that there is no significant difference between both groups and recurrence will occur whether drain would be placed or not but it was also noticed that rate of recurrence was lower with subdural drain than without drain after burr hole evacuation of chronic subdural hematoma. Some other factor may be involved for recurrence so a long study is required to reach proper conclusion.

Author Biographies

Dr. Liaqat Mahmood Awan

Department of Neurosurgery,

Dr Ejaz Hussain Wadd, Lahore General Hospital, Lahore

Department of Neurosurgery

Dr. Asif Shabir, Lahore General Hospital, Lahore

Department of Neurosurgery

Dr. Khawar Anwar, Lahore General Hospital, Lahore

Department of Neurosurgery


1. Le Roux A, Nadvi S. Acute extradural haematoma in the elderly. British journal of neurosurgery, 2007; 21 (1): 16-20.
2. Callaway DW, Wolfe R. Geriatic trauma. Emer Med Clin N Amer. 2007; 25: 857-60.
3. Sinha V, Gupta V, Singh DK, Chopra S, Gupta P, Bagaria H. Geriatric head injuries—Experience and expectations. The Indian Journal of Neurotrauma, 2008; 5 (2): 69-73.
4. Soto-Granados M. Treatment of chronic subdural haematoma through a burr hole. Cir Cir. 2010; 78 (3): 203-7.
5. Santarius T, Kirkpatrick PJ, Ganesan D. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomized controlled trial. The Lancet, 2009; 374 (9695): 1067-1073.
6. Weigel R, Schmiedek P, Krauss JK. Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. Journal of Neurology, Neurosurgery & Psychiatry, 2003; 74 (7): 937-43.
7. Han HJ, Park CW, Kim EY, Yoo CJ, Kim YB and Kim WK. One vs. Two Burr Hole Craniostomy in Surgical Treatment of Chronic Subdural Haematoma. J Korean Neurosurg Soc. 2009; 46 (2): 87–92.
8. Ishfaq A, Ahmed I, Bhatti SH .Effect of head positioning on outcome after burr hole craniostomy for chronic subdural haematoma. Journal of the College of Physicians and Surgeons Pakistan, 2009; 19 (8): 492-495.
9. Yi-hui Ma, Zhou Fei. Management of chronic subdural haematoma. The Lancet, 2010; 375 (9710): 195.
10. Taussky P, Fandino J, Landolt H. Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma. Br J Neurosurg. 2008; 22 (2): 279-82.
11. Lind CR, Lind CJ, Mee EW. Reduction in the number of repeated operations for the treatment of subacute and chronic subdural haematoma by placement of subdural drains. J Neurosurg. 2004; 100 (1): 169-70.
12. Hackney D. Radiologic imaging procedures. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 419.
13. Cohen M, Scheimberg I. Subdural haemorrhage and child maltreatment. Lancet, 2009; 373 (9670): 1173.
14. Muzii VF, Bistazzoni S, Zalaffi A, Carangelo B, Mariottini A, Palma L. Chronic subdural hematoma: comparison of two surgical techniques. Preliminary results of a prospective randomized study. J Neurosurg Sci. 2005; 49 (2): 41-6.
15. Sambasivan M. An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol. 1997; 47: 418-22.
16. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complication and recurrence rate. Neurol Med Chir (Tokyo), 2001; 41: 371-81.
17. Ernestus RI, Beldzinski P, Lanfermann H, Klug N. Chronic subdural hematoma: Surgical treatment and outcome in 104 patients. Surg Neurol. 1997; 48: 220-5.
18. Matsumoto K, Akagi K, Abekura M, Ryujin H, Ohkawa M, Iwase N, et al. Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage. Neurol Res. 1999; 21: 277-80.
19. Mellergard O, Wisten O. Operations and re-operations for chronic subdural hematomas during a 25 – year period in a well defined population. Acta Neurochir (Wein), 1996; 138: 708-13.
20. Tsutsumi K, Maeda K, Iijima A, Usui M, Okada Y, Kirino T. The relationship of preoperative magnetic resonance imaging findings and closed system drainage in the recurrence of chronic subdural hematoma. J Neurosurg. 1997; 87: 870-5.
21. Khadka NK, Sharma GR, Roka YB, Kumar P, Bista P, Adhikari D, Devkota UP. Nepal Med Coll J. Single burr hole drainage for chronic subdural hematoma, 2008 Dec; 10 (4): 254-7.
22. Gökmen M, Sucu HK, Ergin A, Gökmen A, Bezircio Lu H. Randomized comparative study of burr-hole craniostomy versus twist drill craniostomy; surgical management of unilateral hemispheric chronic subdural hematomas. Zentralbl Neurochir. 2008 Aug; 69 (3): 129-33. Doi: 10.1055/s-2007-1004587. Epub 2008 Jul 29.
23. Stephan Emich1* , Bernd Richling2 , Marc R McCoy3 , Rahman Abdul Al-Schameri1 , Feng Ling4 , Liyong Sun4 , Yabing Wang4 and Wolfgang Hitzl2 . The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma – the DRESH study: straightforward study protocol for a randomized controlled trial. Trials, 2014, 15: 6. Doi: 10.1186/1745- 6215-15-6.
24. Anticonvulsants for preventing seizures in patients with chronic subdural haematoma. Ratilal BO1 , Pappamikail L, Costa J, Sampaio C. Cochrane Database Syst Rev. 2013 Jun. 6; 6: CD004893. Doi: 10.1002/14651858.CD004893.pub3.
25. A Shameem .MS, Agrawal D .M Ch, Kale SS M Ch et al, Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India. A comparative study of treatment of chronic subdural hematoma – burr hole drainage versus continuous closed drainage ..Indian Journal of Neurotrauma (IJNT1), 2011; Vol. 8, No. 1: pp. 17-24.
26. Z J. Chris. H Leo. B M Ross. Surgical Management of Traumatic Brain Injury. Youmans Neurological Surgery, 2011, Vol. 4: pp. 3447-3448.
Original Articles