New, Simple Technique for cSDH Cuts Recurrence by 50%

Using irrigation warmed to body temperature during burr hole evacuation for chronic subdural hematoma (cSDH) cuts the risk for recurrence by more than half compared and should become the standard of care, new research suggests.

Results from the multicenter randomized controlled trial found that irrigation at 37° C (body temperature) offered better clinical outcomes than surgery with irrigation at 22° C (room temperature) with no significant differences in complications, quality of life or mortality.

“Using irrigation at body temperature significantly reduces the rate of recurrence compared to irrigation at room temperature,” lead investigator Andreas Bartley, MD, neurosurgeon at Sahlgrenska University Hospital in Gothenburg, Sweden, told Medscape Medical News. “A decrease in re-operations not only decreases the risk of complications for the individual patient but also decreases the load on the healthcare system.”

The findings were published online November 21 in JAMA Neurology.

Expected Increase in Cases

Chronic subdural hematoma is usually caused by head trauma and occurs most frequently in elderly people. Studies suggest cases of cSDH have increased significantly in recent years, with an expected annual case load in the US of 60,000 by 2030.

Burr hole evacuation combined with a postoperative drain is the most common surgical technique used to treat subdural hematoma. Between 10%-20% of patients who undergo burr hole evacuation for cSDH have a recurrence requiring additional surgery, often leading to increased morbidity and mortality.

Prior studies have produced conflicting results on how often irrigation is used during surgery and whether irrigation temperature affects outcomes.

To investigate, 541 patients at 3 Swedish medical centers underwent burr hole evacuation with irrigation for cSDH either at room temperature (RT) or body temperature (BT). The majority of patients were male with a mean age of 75.8 years.

After a 6-month follow up, incidence of SDH recurrence was 6% in the BT group compared with 14% in those whose surgeries included irrigation at room temperature (odds ratio, 2.56; P < .001).

Most recurrences in both groups occurred within the first 2 months following the initial surgery.

Mortality was 7% in the room temperature group vs 5% in the body temperature group, with no significant differences between groups. Complication frequency and quality of life were also similar regardless of irrigation temperature.

New Standard of Care?

There are several reasons why irrigation temperature may influence recurrence risk, Barley noted.

“We believe that both an improved intraoperative coagulation and increased solubility are equally possible when irrigation at body temperature is used,” Barley said.

Although there are other studies examining refinements to cSDH surgery underway, researchers believe these findings could make the use of body temperature irrigation more widespread.

“We believe it will gain support,” Bartley said. “Already today, irrigation at body temperature is used in many departments, and it is easy to implement in clinical practice without great cost or effort.”

The researchers conclude that this “safe, simple, and readily available technique” has the potential to optimize outcomes in cSDH. “When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care,” the investigators write.

The study was funded by Gothenburg Society of Medicine, the Region Västra Götaland and Hjalmar Svensson. Study authors reported no relevant financial relationships.

JAMA Neuro. Published online November 21, 2022. Full text

Kelli Whitlock Burton is a reporter for Medscape Medical News covering neurology and psychiatry.

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