title: The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom.
abstract: OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.
authors.affiliation: Department of Clinical Neurosciences, Western General Hospital, Edinburgh.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Brennan
authors.affiliation: Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge.
authors.forename: Angelos G
authors.initials: AG
authors.lastname: Kolias
authors.affiliation: Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge.
authors.forename: Alexis J
authors.initials: AJ
authors.lastname: Joannides
authors.affiliation: Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Shapey
authors.affiliation: Department of Neurosurgery, Charing Cross Hospital, London.
authors.forename: Hani J
authors.initials: HJ
authors.lastname: Marcus
authors.affiliation: Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Gregson
authors.affiliation: Department of Neurosurgery, Royal London Hospital, London; and.
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Grover
authors.affiliation: Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Hutchinson
authors.affiliation: Department of Neurosurgery, James Cook Hospital, Middleborough, United Kingdom.
authors.forename: Ian C
authors.initials: IC
authors.lastname: Coulter
keywords: BHC = bur-hole craniostomy; BNTRC = British Neurosurgical Trainee Research Collaborative; CSDH = chronic subdural hematoma; GCS = Glasgow Coma Scale; INR = international normalized ratio; NSU = neurosurgical unit; ORION = Outcome Registry Intervention and Operation Network; RCT = randomized controlled trial; SBNS = Society of British Neurological Surgeons; TDC = twist-drill craniostomy; UK = United Kingdom; chronic subdural hematoma; mRS = modified Rankin Scale; neurosurgery; outcomes; vascular disorders