1
Description of the 250 eligible studies
Author/
Year
Study
Design
Quality Assessment
Study Population
Outcomes
Gomez Mendz1
(1971)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
33 patients with chronic subdural
hematomas. Managed with
frontoparietal craniotomy.
Morbidity: 2 (epidural hematoma), 2
(subdural hematomas), 1
(osteomyelitis). Good recovery: 28.
Kak et al2
(1971)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
66 patients with 74 chronic subdural
hematomas. Managed with two burr holes craniostomy. 15 had drains.
Morbidity: 6. Good recovery: 6.
Recurrence rate: 3, managed with craniotomy and membranectomy.
Hirakawa et al3 (1972)
Retrospective observational
study
Newcastle-Ottawa Scale: High
309 patients with chronic subdural hematomas. 170 managed with
craniotomy and 133 with burr hole
craniostomy. 166 had irrigation.
Morbidity: 6. Good recovery: craniotomy: 104/114, burr hole:
84/89. Recurrence rate: craniotomy:
28, burr hole: 15.
Waga et al4
(1972)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
24 patients with 28 chronic subdural
hematomas. 8 managed with
craniotomy and 20 with burr hole craniostomy.
Mortality: 0. Morbidity: 1 (epidural
hematoma). Good recovery: 23.
Recurrence rate: 2.
Bender et al5 (1974)
Retrospective observational
study
Newcastle-Ottawa Scale: High
185 patients with chronic subdural hematomas. 75 managed medically,
88 surgically, and 22 with both. 37
had adjuvant corticosteroids and 60 had bed rest.
Mortality: 14. Good recovery: 162.
So et al6
(1977)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
20 patients with 24 chronic subdural
hematomas. Managed with two burr hole craniostomy. 20 had irrigation
and 20 had bed rest.
Mortality: 2. Morbidity: 1
(pneumonia). Good recovery: 12. Recurrence rate: 5, managed with
retapping the subdural space. Second
recurrence: 2.
Tabaddor et al7
(1977)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
71 patients with chronic subdural
hematomas. 21 managed with percutaneous twist drill drainage, 22
with burr hole craniostomy, and 28
with craniotomy with or without membranectomy. 21 had drains and
bed rest for 24 hours.
Mortality: percutaneous drainage: 2,
burr hole: 5, craniotomy: 8. Morbidity: 2 (stroke). Good recovery:
percutaneous drainage: 18, burr hole:
9, craniotomy: 11. Recurrence rate: percutaneous drainage: 1, burr hole:
3, craniotomy: 3.
Cameron8
(1978)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
114 patients with 127 chronic
subdural hematomas. 2 patients
used anticoagulants. 112 managed with two burr hole craniostomy and
2 with craniotomy. 112 had
irrigation.
Mortality: 5. Morbidity: 1 (infection
and subdural abscess), 3 (seizure), 1
(communicating hydrocephalus), 6 (increase in seizure frequencies).
Good recovery: 101. Recurrence rate:
3, managed with two burr holes.
Gilsbach et al9
(1980)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
51 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 51 had drains and irrigation.
Mortality: 1. Good recovery: 26.
Recurrence rate: 11.
Hubschmann10
(1980)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
22 patients with chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 22
had drains for 24 hours with 0 bed rest.
Mortality: 5. Morbidity: 1 (sepsis), 2
(aspiration pneumonia and cardiac
arrest), 1 (fatal pulmonary embolism),
1 (massive basilar artery stroke), 2 (failure of procedure). Good
recovery: 15. Recurrence rate: 2,
managed with percutaneous drainage and craniotomy. Second recurrence:
0.
Arbit et al11 Retrospective Newcastle-Ottawa Scale: 25 patients with chronic subdural Morbidity: 0. Good recovery: 22.
2
(1981) observational
study
Low hematomas. 5 used anticoagulants.
Managed with burr hole craniostomy. 25 had implantable
drains.
Recurrence rate: 5, managed with
percutaneous needle. Second recurrence: 1.
Iwabuchi et al12 (1981)
Retrospective observational
study
Newcastle-Ottawa Scale: High
60 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 60 had irrigation.
Morbidity: 0. Good recovery: 60. Recurrence rate: 0.
Markwalder et
al13 (1981)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
32 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 0 had adjuvant corticosteroids. 32 had drains for 48
hours and bed rest.
Mortality: 0. Morbidity: 0. Good
outcome: 31. Recurrence rate: 1,
managed with craniotomy and membranectomy. Second recurrence:
0.
Moringlane et al14 (1981)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
31 patients with 41 chronic subdural hematomas. 30 managed with
enlarged burr hole craniostomy. 30
had drains and irrigation.
Mortality: 6. Morbidity: 1 (superficial intracerebral hematoma), 1 (subdural
empyema). Good recovery: 4.
Ohaegbulam15
(1981)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
132 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 132 had irrigation
and 0 had drains.
Mortality: 1. Morbidity: 25
(postoperative seizure). Good recovery: 82. Recurrence rate: 0.
Victoratos et al16 (1981)
Prospective observational
study
Newcastle-Ottawa Scale: High
20 patients with chronic subdural hematomas. 17 managed with burr
hole craniostomy and 3 conservatively. 1 patient had
adjuvant corticosteroids.
Mortality: 0. Good recovery: 20. Recurrence rate: 2, managed with
burr hole.
Izumi et al17 (1982)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
17 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 16 had drains.
Mortality: 0. Morbidity: 0. Good recovery: 16. Recurrence rate: 1.
Moussa et al18
(1982)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
24 patients with chronic subdural
hematomas. 16 managed with two
burr hole craniostomy and 8 with one burr hole. 24 had irrigation. 0
had drains and 0 had bed rest.
Mortality: 1. Morbidity: 1
(fulminating bronchopneumonia).
Good recovery: 24. Recurrence rate: 0.
Kitami et al19 (1983)
Retrospective observational
study
Newcastle-Ottawa Scale: High
22 patients with chronic subdural hematomas. Managed with
percutaneous twist drill drainage. 22
had drains for 72 hours.
Mortality: 0. Morbidity: 0. Good recovery: 22.
Weir20
(1983)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
71 patients with chronic subdural
hematomas. 69 managed with one burr hole craniostomy. 69 had
drains.
Mortality: 2. Morbidity: 1 (infection).
Recurrence: 8.
Aoki21 (1984)
Retrospective observational
study
Newcastle-Ottawa Scale: High
39 patients with chronic subdural hematomas. Managed with
percutaneous twist drill drainage. 15 had irrigation and 0 had drains.
Morbidity: 0. Good recovery: 17 (no irrigation), 14 (irrigation). Recurrence
rate: 7 (no irrigation), 1 (irrigation), 3 managed with subdural tapping and 5
with burr hole.
Eggert et al22
(1984)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
100 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 100 had closed
system drainage.
Recurrence rate: 16, managed with
burr hole.
Li et al23
(1984)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
80 patients with chronic subdural
hematomas. 70 managed with craniotomy, 8 with burr hole
craniostomy, and 2 conservatively.
Mortality: 4. Morbidity: 2
(intermittent attacks of seizure). Good recovery: 65/65. Recurrence rate: 3,
managed with craniotomy. Second
recurrence: 0.
Patrick et al24 Retrospective Newcastle-Ottawa Scale: 16 patients with chronic subdural Mortality: 1. Good recovery: 12.
3
(1984) observational
study
Low hematomas. 0 used anticoagulants.
15 managed with burr hole craniostomy, 1 managed
conservatively.
Richter et al25 (1984)
Retrospective observational
study
Newcastle-Ottawa Scale: High
120 patients with 143 chronic subdural hematomas. 2 used
anticoagulants. 0 had adjuvant
corticosteroids. 120 managed with burr hole craniostomy. 120 had
irrigation and drainage with closed
system for 96 hours. 0 had bed rest.
Mortality: 5. Morbidity: 1 (deep intracerebral hemorrhage), 1 (cardiac
insufficiency and
bronchopneumonia), 3 (epidural hematoma). Good recovery: 114.
Recurrence rate: 2.
Robinson26
(1984)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
133 patients with 159 chronic
subdural hematomas. 123 managed with burr hole craniostomy and 10
managed with craniotomy. 123 had
irrigation.
Mortality: 2. Morbidity: 1 (transient
hemiparesis), 1 (worsened consciousness), 24 (intracranial
hypotension), 20 (permanent
neurological disability), 1 (subdural infection), 1 (infected secondary bone
flap).
Kawakami et al27 (1985)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
23 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 11 had closed
system drainage and 23 had irrigation.
Mortality: 1. Morbidity: 1 (left hemiplegia/intracerebral hematoma),
1 (tension pneumocephalus). Good
recovery: 21.
Markwalder et al28 (1985)
Prospective observational
study
Newcastle-Ottawa Scale: High
21 patients with chronic subdural hematomas. 1 used anticoagulants.
Managed with two burr hole
craniostomy. 0 had adjuvant corticosteroids. 21 had irrigation, 21
had bed rest for 24 hours, and 0 had
drains.
Mortality: 0. Good recovery: 20. Recurrence rate: 2, managed with
burr hole. Second recurrence: 1.
Camel et al29
(1986)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
114 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage.
114 had drains.
Mortality: 9. Morbidity: 1 (broken
catheter). Good recovery: 98. Recurrence rate: 12, 9 managed with
craniotomy and 3 with re-
trephination. Second recurrence: 2.
Markwalder et
al30 (1986)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
232 patients with chronic subdural
hematomas. 26 used anticoagulants.
231 managed with burr hole craniostomy and 1 with craniotomy.
200 had closed system drainage,
irrigation, and bed rest.
Mortality: 5. Morbidity: 5 (subdural
empyema), 4 (neurological deficits
such as reflex asymmetry or mild hemiparesis), 1 (pulmonary
embolism), 1 (pneumonia). Good
recovery: 30/31. Recurrence rate: 9.
Aydin et al31
(1987)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
43 patients with 52 chronic subdural
hematomas. Managed with burr hole craniostomy. 43 had closed
system drainage.
Mortality: 14.
Cheah et al32
(1987)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
48 patients with chronic subdural
hematomas. 38 managed with one
burr hole craniostomy and 10 with two burr holes. 48 had drains and
irrigation.
Mortality: 0. Morbidity: 2 (minor
superficial infections), 1 (subdural
empyema). Good recovery: 39. Recurrence rate: 9, managed with
repeated aspiration. Second
recurrence: 0.
Kotwica et al33
(1987)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
90 patients with chronic subdural
hematomas. 61 managed with burr
hole craniostomy and 29 with craniotomy and capsulectomy.
Mortality: burr hole: 1, craniotomy:
6.
Pichert et al34 (1987)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
66 patients with chronic subdural hematomas. 13 managed surgically
and 53 medically with
corticosteroids and bed rest.
Good recovery: corticosteroids: 38/46. Recurrence rate:
corticosteroids: 8.
4
Yoshii et al35
(1987)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
68 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 68 had irrigation.
Recurrence rate: 11.
Chiang et al36
(1988)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
23 patients with 32 chronic subdural
hematomas. Managed with one burr hole craniostomy. 23 had drains and
bed rest. 0 had irrigation.
Mortality: 0. Morbidity: 0. Good
recovery: 22. Recurrence rate: 1, managed with craniotomy and
capsulectomy. Second recurrence: 0.
Grisoli et al37
(1988)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
100 patients with chronic subdural
hematomas. 10 used anticoagulants.
Managed with craniectomy. 100 had irrigation. 0 had adjuvant
corticosteroids.
Mortality: 2. Morbidity: 2
(empyema), 3 (decubitus infection), 3
(seizure), 1 (partial motor deficit). Good recovery: 96. Recurrence rate:
2, managed with craniectomy. Second
recurrence: 0.
Hirai et al38
(1989)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
239 patients with chronic subdural
hematomas. 226 managed with two
burr holes and 13 conservatively. 226 had irrigation. 0 had drains.
Mortality: 5. Good recovery: 179.
Recurrence rate: burr hole: 24.
Iwadate et al39 (1989)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
59 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 59 had irrigation.
0 had drains.
Morbidity: 0. Recurrence rate: 1.
Laumer et al40
(1989)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
144 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 48 had permanent
subdural drains with subcutaneous
reservoir, 49 had external closed system drainage, and 42 had no
drainage.
Morbidity: permanent drainage: 1
(infection), 2 (seizure), external drainage: 2 (infection), 1 (seizure), no
drainage: 1 (infection), 2 (seizure).
Recurrence rate: permanent drainage: 3, external drainage: 13, no drainage:
12, managed with burr hole.
Spallone et al41 (1989)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
131 patients with 160 chronic subdural hematomas. Managed with
enlarged burr hole craniostomy. 131
had closed system drainage and irrigation.
Mortality: 4. Morbidity: 7 (systemic complications including pneumonia,
cardiac features, thrombophlebitis,
and urinary tract infection). Recurrence rate: 10.
Li42 (1990)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
60 patients with chronic subdural hematomas. 59 managed with burr
hole craniostomy. 59 had drains and
irrigation.
Mortality: 3. Good recovery: 57.
Salomão et al43
(1990)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
96 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy.
Mortality: 12. Good recovery: 78.
Wakai et al44
(1990)
Prospective
observational study
Newcastle-Ottawa Scale:
High
38 patients with 47 chronic subdural
hematomas. 0 used anticoagulants. Managed with one burr hole
craniostomy. 20 had closed system
drainage and 38 had irrigation.
Mortality: drainage: 3, no drainage: 1.
Morbidity: drainage: 1 (pneumonia), 1 (myocardial infarction), 1 (renal
failure). no drainage: 1 (pneumonia).
Good recovery: drainage: 16, no drainage: 10. Recurrence rate:
drainage: 1, no drainage: 6, managed
with re-irrigation. Second recurrence: 0.
Drapkin45 (1991)
Retrospective observational
study
Newcastle-Ottawa Scale: High
53 patients with 56 chronic subdural hematomas. 5 used anticoagulants.
Managed with two burr hole
craniostomy. 53 had closed system drainage and irrigation.
Mortality: 3. Morbidity: 1 (post-operative sepsis and unilateral
subdural empyema), 1 (pneumonia), 1
(brainstem stroke), 2 (small intraparenchymatous bleeds in
cerebral hemispheres ipsilateral to
hematoma), 1 (superficial infection at burr hole site), 3 (post-operative
seizure). Good recovery: 41.
Recurrence rate: 10.
5
Kotwica et al46
(1991)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
131 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with two burr hole
craniostomy. 131 had closed system
drainage and irrigation.
Mortality: 4. Morbidity: 8
(intracranial hypotension), 4 (cerebral edema), 3 (bronchopneumonia), 1
(intracerebral hematoma), 12
(hemiparesis or dementia), 9 (seizure). Good recovery: 108.
Recurrence rate: 3, managed with two
burr holes. Second recurrence: 0.
Rychlicki et
al47 (1991)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
65 patients with 76 chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 65 had closed system drainage and
irrigation.
Mortality: 0. Morbidity: 1
(bronchopneumonic complication).
Good recovery: 65. Recurrence rate: 2, 1 managed with percutaneous
drainage and 1 with craniectomy.
Second recurrence: 1.
Ueno et al48
(1991)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
64 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 64 had irrigation.
0 had drains.
Mortality: 2. Morbidity: 0. Good
recovery: 53. Recurrence rate: 0.
Vilalta et al49 (1991)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
68 patients with chronic subdural hematomas. Managed with
percutaneous twist drill drainage. 68
had closed system drainage. 0 had irrigation.
Mortality: 6. Recurrence rate: 12.
Aoki50 (1992)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
40 patients with 45 chronic subdural hematomas. Managed with
percutaneous twist drill drainage. 40
had drains and 0 had irrigation.
Morbidity: 0. Good recovery: 40. Recurrence rate: 2, 1 managed with
percutaneous drainage and 1 with
burr hole. Second recurrence: 1.
Fu51
(1992)
Retrospective observational study
Newcastle-Ottawa Scale:
Low
95 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 95 had irrigation.
Morbidity: 5.
Adam et al52
(1993)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
69 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy.
Mortality: 12. Morbidity: 2 (seizure),
12 (bronchopneumonia), 2 (myocardial infarction), 1 (acute
abdomen). Good recovery: 38.
Recurrence rate: 4.
Aoki et al53
(1993)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
20 patients with 23 chronic subdural
hematomas. Managed with percutaneous twist drill drainage. 20
had drainage. 0 had irrigation.
Mortality: 0. Morbidity: 0. Good
recovery: 20.
Chung et al54 (1993)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
97 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 97 had drainage.
Mortality: 4. Cure rate: 65.
Hamilton et al55
(1993)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
92 patients with 112 chronic
subdural hematomas. 7 used
anticoagulants. 49 managed with craniotomy and 43 with burr hole
craniostomy. 49 had drains.
Mortality: craniotomy: 2, burr hole:
2. Morbidity: craniotomy: wound
infection (2 without drainage, 1 with drainage), other infection (1 without
drainage), other systemic
complications (3 without drainage, 1 with drainage), burr hole: wound
infection (1 without drainage), other
infection (3 with drainage), other systemic complications (1 without
drainage, 1 with drainage). Good
recovery: 47. Recurrence rate: craniotomy: 4 (without drainage), 1
(with drainage), burr hole: 0 (without
drainage), 3 (with drainage).
Ram et al56
(1993)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
37 patients with 41 chronic subdural
hematomas. 0 used anticoagulants.
Mortality: 0. Morbidity: with
irrigation: 1 (occipital infarct), 1
6
Managed with two burr hole
craniostomy. 37 had drains for 48 hours and 19 had irrigation.
(transient deterioration of
consciousness with hemiparesis), without irrigation: 1 (tension
pneumocephalus), 1 (cortical
contusion), 1 (subdural empyema), 1 (superficial wound infection). Good
recovery: 37. Recurrence rate: 1 with
irrigation, 4 without irrigation, managed with two burr holes. Second
recurrence: 0.
Benzel et al57 (1994)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
111 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 111 had
irrigation. 0 had drains.
Mortality: 4. Morbidity: 2 (sepsis), 2 (myocardial infarction/pulmonary
embolus), 1 (symptomatic tension
pneumocephalus). Good recovery: 100. Recurrence rate: 12, managed
with burr hole. Second recurrence: 7.
Choudhury58
(1994)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
44 patients with 51 chronic subdural
hematomas. 4 used anticoagulants.
Managed with two burr hole craniostomy. 44 had drains,
irrigation, and bed rest.
Mortality: 0. Morbidity: 1 (cerebral
edema), 1 (new contralateral
hematoma). Good recovery: 43. Recurrence rate: 1, managed with
burr hole. Second recurrence: 0.
Weisse et al59 (1994)
Retrospective observational
study
Newcastle-Ottawa Scale: High
106 patients with chronic subdural hematomas. 3 used anticoagulants.
78 managed with two burr hole craniostomy and 28 with
craniectomy. 78 had drains for 48
hours, irrigation, and bed rest.
Mortality: burr hole: 4, craniotomy: 5. Morbidity: burr hole: 5 (post-
operative hemorrhage), 1 (wound infection), 1 (subdural empyema).
Good recovery: burr hole: 66,
craniotomy: 15. Recurrence rate: burr hole: 8.
Kitakami et al60
(1995)
Prospective
observational study
Newcastle-Ottawa Scale:
High
19 patients with 21 chronic subdural
hematomas. Managed with one burr hole craniostomy. 19 had irrigation.
0 had drains and 0 had bed rest.
Mortality: 0. Morbidity: 0. Good
recovery: 18. Recurrence rate: 1.
Krupp et al61
(1995)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
212 patients with chronic subdural
hematomas. 13 used anticoagulants.
Managed with burr hole craniostomy. 212 had irrigation,
drains, and bed rest.
Mortality: 9. Morbidity: 5 (infection
of the wound), 2 (further developed
subdural empyema), 2 (thrombosis in the leg), 1 (pneumonia), 1
(pulmonary edema). Good recovery:
192. Recurrence rate: 53, managed with burr hole. Second recurrence: 7.
Merlicco et al62
(1995)
Prospective
observational study
Newcastle-Ottawa Scale:
High
70 patients with 80 chronic subdural
hematomas. 3 used anticoagulants. Managed with small parietal
craniectomy.70 had drains and
irrigation.
Mortality: 3. Morbidity: 9 (subdural
pneumocephalus), 1 (heart failure with pulmonary edema). Good
recovery: 51. Recurrence rate: 0.
Sabo et al63
(1995)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
98 patients with chronic subdural
hematomas. 85 managed with burr hole craniostomy and 13 with
percutaneous twist drill drainage.
Mortality: 11. Morbidity: 8
(respiratory complication), 3 (increased seizure frequency), 17
(new seizure activity). Good
recovery: 58/85. Recurrence rate: burr hole: 5, percutaneous drainage: 4.
Stroobandt et
al64 (1995)
Retrospective observational
study
Newcastle-Ottawa Scale:
Low
100 patients with 132 chronic
subdural hematomas. 22 used
anticoagulants. Managed with one
burr hole craniostomy. 24 had adjuvant corticosteroids. 100 had
drains.
Mortality: 2. Morbidity: 11. Good
recovery: 85. Recurrence rate: 29,
managed with one burr hole. Second
recurrence: 14.
Bhatty et al65 (1996)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
100 patients with 118 chronic subdural hematomas. 84 managed
with percutaneous twist drill
drainage, 9 with two burr hole
Good recovery: percutaneous drainage: 55, craniotomy: 8.
Recurrence rate: percutaneous
drainage: 26, craniotomy: 0, managed
7
craniostomy, 8 with craniotomy,
and 17 conservatively. 84 had irrigation. 0 had drains.
with percutaneous drainage.
Mellergård et
al66 (1996)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
218 patients with 243 chronic
subdural hematomas. 22 used anticoagulants. Managed with one
burr hole craniostomy. 218 had
drains and irrigation.
Mortality: 7. Morbidity: 1 (subdural
empyema), 6 (cardiovascular problems), 2 (post-operative
hemorrhage). Good recovery: 184.
Recurrence rate: 27. Second recurrence: 4.
Salahuddin67 (1996)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
23 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 23 had irrigation.
0 had drains.
Mortality: 0. Morbidity: 2 (cerebral edema), 1 (superficial wound
infection), 4 (seizure). Good
recovery: 18. Recurrence rate: 3, managed with burr hole. Second
recurrence: 0.
Ernestus et al68 (1997)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
104 patients with 123 chronic subdural hematomas. 6 used
anticoagulants. 94 managed with
burr hole craniostomy and 10 with craniotomy. 104 had drains and
irrigation.
Mortality: burr hole: 2, craniotomy: 2. Good recovery: burr hole: 55,
craniotomy: 5. Recurrence rate: burr
hole: 17, craniotomy: 1.
Sambasivan69
(1997)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
2300 patients with 2880 chronic
subdural hematomas. 51 managed
with multiple burr hole craniostomy, 9 with one burr hole,
2215 with craniotomy and
subtemporalis marsupialization, and 6 with craniotomy and
membranectomy. 2281 had drains
for 24 hours and irrigation.
Mortality: multiple burr: 2, one burr:
0, craniotomy subtemporalis
marsupialization: 11, craniotomy and membranectomy: 0. Morbidity:
multiple burr: 2 (infection). Good
recovery: multiple burr: 49, one burr: 9. craniotomy subtemporalis
marsupialization: 2204, craniotomy
and membranectomy: 6. Recurrence rate: multiple burr: 11, craniotomy
subtemporalis marsupialization: 8,
managed with multiple aspirations, burr hole, and membranectomies.
Smely et al70 (1997)
Prospective observational
study
Newcastle-Ottawa Scale: High
66 patients with 76 chronic subdural hematomas. 1 used anticoagulants.
33 managed with percutaneous
twist drill drainage and 33 with one burr hole craniostomy. 66 had
drains and 33 had irrigation.
Mortality: percutaneous drainage: 2, burr hole: 3. Morbidity: percutaneous
drainage: 0, burr hole: 1 (cardiac
arrest), 1 (severe pain), 6 (wound infection or manifestation of
meningitis). Good recovery:
percutaneous drainage: 31, burr hole: 30. Recurrence rate: percutaneous
drainage: 6, burr hole: 11, managed
with percutaneous drainage and burr hole. Second recurrence:
percutaneous drainage: 0, burr hole:
2.
Tsutsumi et al71
(1997)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
199 patients with 230 chronic
subdural hematomas. Managed with one burr hole craniostomy. 162 had
drains and 199 had irrigation.
Mortality: 0. Morbidity: 0.
Recurrence rate: with drainage: 3/177, without drainage: 9/53.
Yoshimoto et
al72 (1997)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
20 patients with 22 chronic subdural
hematomas. Managed with burr
hole craniostomy. 20 had irrigation.
0 had drains.
Mortality: 0. Morbidity: 0. Good
recovery: 18. Recurrence rate: 2.
Zumkeller et
al73 (1997)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
314 patients with chronic subdural
hematomas. 21 used anticoagulants. Managed with burr hole
craniostomy.
Mortality: 22. Morbidity: 15
(infection), 8 (secondary hemorrhage), 9 (pneumonia), 16
(seizure).
De Jesús et al74 Retrospective Newcastle-Ottawa Scale: 220 patients with 255 chronic Mortality: 2. Morbidity: 14
8
(1998) observational
study
Low subdural hematomas. 115 managed
with one, 94 with two, and 22 with three burr hole craniostomy and 24
with craniotomy.
(postoperative seizure), 6
(intracerebral hematoma), 2 (tension pneumocephalus), 1 (acute subdural
hematoma). Good recovery: 209.
Recurrence rate: one burr: 13, multiple burr: 7, Craniotomy: 0.
Second recurrence: 3.
Kubota et al75 (1998)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
30 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 30 had irrigation.
Recurrence rate: 4.
Penchet et al76
(1998)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
236 patients with 277 chronic
subdural hematomas. Managed with
burr hole craniostomy. 236 had drains.
Morbidity: 34. Good recovery: 230.
Recurrence rate: 28.
Reinges et al77
(1998)
Prospective
observational study
Newcastle-Ottawa Scale:
High
37 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage.
Morbidity: 0.
Suzuki et al78 (1998)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
186 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 119 had drains
and 67 had irrigation.
Mortality: with irrigation: 1. Morbidity: with irrigation: 2 (acute
epidural hematoma). Recurrence rate:
with irrigation: 2, without irrigation: 4, managed with one burr hole.
Second recurrence: 1.
Villagrasa et
al79 (1998)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
65 patients with chronic subdural
hematomas. Managed with small
craniectomy.
Mortality: 3. Recurrence rate: 1.
Aung et al80
(1999)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
50 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 50 had drains for 48 hours, irrigation, and bed rest.
Morbidity: 0. Good recovery: 50.
Beatty81 (1999)
Prospective observational
study
Newcastle-Ottawa Scale: High
23 patients with chronic subdural hematomas. Managed with
craniotomy. 23 had irrigation and
drains.
Mortality: 2. Morbidity: 0. Good recovery: 21. Recurrence rate: 0.
Emonds et al82
(1999)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
86 patients with chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 86 had drains and irrigation.
Mortality: 2. Morbidity: 2 (local skin
infection), 1 (multi-infarction
syndrome), 1 (pulmonary embolus). Good recovery: 79. Recurrence rate:
22, managed with percutaneous
drainage. Second recurrence: 6.
Hennig et al83
(1999)
Prospective
observational study
Newcastle-Ottawa Scale:
High
137 patients with 153 chronic
subdural hematomas. 128 managed with two burr hole craniostomy and
9 with craniotomy. 17 had drains
and 111 had irrigation (73 continuous for 48 hours and 38
peri-operative).
Mortality: burr hole: 5 (3 irrigation, 2
drainage), craniotomy: 1. Morbidity: burr hole: 3 (2 irrigation, 1 drainage).
Good recovery: 71/73. Recurrence
rate: burr hole: 22 (17 irrigation, 5 drainage), craniotomy: 4. Second
recurrence: 5.
Kaminogo et
al84 (1999)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
38 patients with 44 chronic subdural
hematomas. Managed with one burr
hole craniostomy. 38 had drains for 24 hours and irrigation.
Recurrence rate: 4.
Matsumoto et
al85 (1999)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
121 patients with chronic subdural
hematomas. 92 managed with one burr hole craniostomy and 29 with
two burr holes. 129 had closed
system drainage and 113 had irrigation.
Mortality: 5. Morbidity: 2
(pneumonia), 2 (myocardial infarction). Good recovery: 121.
Recurrence rate: 10. Second
recurrence: 1.
9
Gabarros et al86
(2000)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
188 patients with chronic subdural
hematomas. 83 managed with two burr hole craniostomy and 105 by
percutaneous twist drill drainage.
188 had drains and 83 had irrigation.
Mortality: burr hole: 6, percutaneous
drainage: 3. Morbidity: burr hole: 14, percutaneous drainage: 7. Good
recovery: burr hole: 68, percutaneous
drainage: 100. Recurrence rate: burr hole: 10, percutaneous drainage: 15.
Hsu et al87
(2000)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
100 patients with 105 chronic
subdural hematomas. 96 managed with two burr hole craniostomy and
9 with craniotomy. 30 had drains,
96 had irrigation, and 100 had bed rest.
Mortality: 4. Morbidity: 1
(nosocomial pneumonia), 1 (minor ischemic stroke), 2 (malpositioned
drain). Recurrence rate: 9 (two burr),
7 (two burr and external subdural drainage), 2 (craniotomy), 3
(craniotomy and external subdural
drainage), 9 managed with burr hole, 10 with craniotomy, 2 with shunts.
Kwon et al88 (2000)
Retrospective observational
study
Newcastle-Ottawa Scale: High
145 patients with 175 chronic subdural hematomas. Managed with
burr hole craniostomy. 0 had
adjuvant corticosteroids. 145 had drains, irrigation, and bed rest.
Recurrence rate: 6.
Missori et al89
(2000)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
31 patients with 35 chronic subdural
hematomas. Managed with one burr hole craniostomy. 12 had drains for
24 hours and 31 had irrigation.
Mortality: 2. Morbidity: 2. Good
recovery: 29. Recurrence rate: 2, 1 managed surgically and 1 with low
dose corticosteroids. Second recurrence: 0.
Nakaguchi et
al90 (2000)
Prospective
observational study
Newcastle-Ottawa Scale:
High
135 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with one burr hole
craniostomy. 135 had drains for 48
hours and irrigation.
Recurrence rate: 18.
Ogasawara et
al91 (2000)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
27 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 27 had drains for
24 hours.
Good recovery: 22. Recurrence rate:
0.
Reinges et al92 (2000)
Prospective observational
study
Newcastle-Ottawa Scale: High
118 patients with chronic subdural hematomas. 29 used anticoagulants.
Managed with percutaneous twist
drill drainage. 0 had drains and irrigation.
Mortality: 1. Morbidity: 5 (acute subdural bleeding), 1 (intracerebral
bleeding), 2 (acute subdural bleeding
with acute worsening of the neurological status), 7 (insufficient
hematoma evacuation and failure to
improve in neurological status), 3 (subdural empyema). Good recovery:
89. Recurrence rate: 11, managed
with craniotomy and bed rest. Second recurrence: 0.
Gelabert-González et al93
(2001)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
90 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 90 had closed
system drainage.
Mortality: 7. Good recovery: 69. Recurrence rate: 6.
Gonugunta et
al94 (2001)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
184 patients with chronic subdural
hematomas. 34 used anticoagulants.
Managed with burr hole
craniostomy. 184 had drains and
irrigation.
Mortality: 1 (warfarin), 2 (no
warfarin). Good recovery: 27
(warfarin), 115 (no warfarin).
Recurrence rate: 5 (warfarin), 22 (no
warfarin), 19 managed with repeat burr hole for (no warfarin), 3 with
craniotomy for (no warfarin), 4 with
repeat burr hole for (warfarin), 1 with craniotomy for (warfarin).
Kuroki et al95
(2001)
Retrospective
observational
Newcastle-Ottawa Scale:
Low
101 patients with chronic subdural
hematomas. Managed with one burr
Mortality: 0. Morbidity: 0. Good
recovery: 52 (without irrigation), 45
10
study hole craniostomy. 101 had drains
and 45 had irrigation.
(with irrigation). Recurrence rate: 1
(without irrigation), 5 (with irrigation).
Leung et al96
(2001)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
108 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 46 had drains for
24 hours and 108 had irrigation.
Mortality: 4. Morbidity: 2 (seizure), 1
(intracranial infection). Recurrence rate: 6, 5 managed with burr hole and
1 with craniotomy. Second
recurrence: 0.
Mori et al97
(2001)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
500 patients with chronic subdural
hematomas. 26 used anticoagulants. Managed with two burr hole
craniostomy. 500 had drains and
irrigation.
Mortality: 6. Morbidity: 13 (acute
subdural hematoma), 4 (tension pneumocephalus), 2 (cerebral
infarction), 1 (putaminal
hemorrhage), 1 (acute epidural hematoma), 1 (subdural empyema), 1
(wound opening), 2 (pneumonia), 1
(ileus), 1 (disseminated intravascular coagulation).
Nakaguchi et
al98 (2001)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
106 patients with 126 chronic
subdural hematomas. 0 used anticoagulants. 105 managed with
burr hole craniostomy. 105 had
closed system drainage for 48 hours, irrigation, and bed rest.
Recurrence rate: 21.
Oishi et al99 (2001)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
116 patients with 134 chronic subdural hematomas. 11 used
anticoagulants. Managed with one
burr hole craniostomy. 116 had drains and irrigation.
Recurrence rate: 10 (8 with irrigation, 2 without irrigation), 9 managed with
reoperation, 1 conservatively.
Shono et al100 (2001)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
20 patients with chronic subdural hematomas. Managed with burr
hole craniostomy.
Recurrence rate: 0.
Tanikawa et al101 (2001)
Retrospective observational
study
Newcastle-Ottawa Scale: High
49 patients with 48 chronic subdural hematomas. 33 managed with two
burr hole craniostomy and 16 with
craniotomy. 49 had drains and irrigation.
Mortality: burr hole: 1. Morbidity: burr hole: 1 (systemic infection and
multiple organ failure). Good
recovery: burr hole: 27, craniotomy: 16. Recurrence rate: burr hole: 4.
Williams et al102 (2001)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
62 patients with chronic subdural hematomas. 51 managed with one
burr hole craniostomy and 11 with
percutaneous twist drill drainage. 25 had drains and 51 had irrigation.
Mortality: 2. Good recovery: burr hole: 31 (no drainage), 13 (drainage),
percutaneous drainage: 4. Recurrence
rate: burr hole: 4 (no drainage), 1 (drainage), percutaneous drainage: 7.
Hirashima et
al103 (2002)
Prospective
observational study
Newcastle-Ottawa Scale:
High
39 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 0 had adjuvant
corticosteroids. 39 had irrigation.
Recurrence rate: 7, 5 managed
surgically and 2 conservatively. Second recurrence: 0.
Ishikawa et
al104 (2002)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
26 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 26 had drains and irrigation.
Good recovery: 17.
Liliang et al105 (2002)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
75 patients with 91 chronic subdural hematomas. 2 used anticoagulants.
Managed with burr hole
craniostomy. 75 had drains for 48 hours and irrigation.
Mortality: 1. Morbidity: 2 (meningitis), 1 (pneumonia). Good
recovery: 69. Recurrence rate: 3.
Second recurrence: 0.
Nakajima et
al106 (2002)
Randomized
trial
See results of the Cohcrane
risk of bias assessment tool
46 patients with chronic subdural
hematomas. 25 used anticoagulants. Managed with one burr hole
craniostomy. 0 had drains, 46 had
Recurrence rate: 4 (bed rest), 3 (no
bed rest).
11
irrigation, and 25 had bed rest for
72 hours.
Okada et al107
(2002)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
40 patients with chronic subdural
hematomas. 0 used anticoagulants.
Managed with one burr hole craniostomy. 20 had drains,
irrigation, and bed rest.
Recurrence rate: 1 (drainage), 5
(irrigation). Second recurrence: 0.
Rohde et al108
(2002)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
376 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 376 had drains, irrigation, and bed rest.
Mortality: 50. Morbidity: 51
(seizure), 8 (intracerebral
hemorrhage), 8 (subdural empyema), 5 (epidural hematoma), 4
(pneumocephalus), 1 (intracerebral
abscess), 29 (pneumonia), 1 (pneumothorax), 9 (cardiac
arrhythmia), 1 (myocardial
infarction), 3 (decompensating heart insufficiency), 7
(thrombosis/pulmonary embolism), 6
(sepsis), 2 (gastric ulceration), 1 (renal failure). Good recovery: 259.
Recurrence rate: 119, 37 managed
with craniotomy and 82 with burr hole.
Sato et al109 (2002)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
195 patients with 210 chronic subdural hematomas. Managed with
one burr hole craniostomy. 195 had
drains for 24 hours.
Mortality: 1. Morbidity: 9. Recurrence rate: 18.
van Eck et al110
(2002)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
53 patients with 69 chronic subdural
hematomas. 4 used anticoagulants.
Managed with percutaneous twist drill drainage. 53 had drains and
irrigation.
Mortality: 2. Morbidity: 0. Good
recovery: 44. Recurrence rate: 8, 5
managed with burr hole and 3 with percutaneous drainage.
Asfora et al111
(2003)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
32 patients with chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 32 had drains and bed rest. 0 had
irrigation.
Good recovery: 26. Recurrence rate:
6. Second recurrence: 0.
Imaizumi et al112 (2003)
Prospective observational
study
Newcastle-Ottawa Scale: High
50 patients with 59 chronic subdural hematomas. 15 used anticoagulants.
36 managed with one burr hole
craniostomy and 23 conservatively. 36 had irrigation.
Recurrence rate: 2. Second recurrence: 0.
König et al113 (2003)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
21 patients with chronic subdural hematomas. 12 used anticoagulants.
15 managed with burr hole
craniostomy and 6 with craniotomy. 15 had drains.
Good recovery: burr hole: 7, craniotomy: 3. Recurrence rate: burr
hole: 3, craniotomy: 2.
Kubo et al114 (2003)
Prospective observational
study
Newcastle-Ottawa Scale: High
34 patients with 35 chronic subdural hematomas. Managed with one burr
hole craniostomy. 34 had drains,
irrigation, and bed rest.
Good recovery: 34. Recurrence rate: 2, managed with one burr hole.
Lind et al115
(2003)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
407 patients with 500 chronic
subdural hematomas. 80 used
anticoagulants. 188 managed with one burr hole craniostomy and 310
with two burr holes. 310 had drains
and 500 had irrigation.
Mortality: 5. Morbidity: 5 (subdural
empyema) 1 with drainage and 4 with
no drainage. Recurrence rate: 31 (with drainage), 35 (no drainage).
Liu et al116
(2003)
Retrospective
observational
Newcastle-Ottawa Scale:
Low
156 patients with chronic subdural
hematomas. Managed with burr
Mortality: 2. Good recovery: 143.
Recurrence rate: 8.
12
study
hole craniostomy. 156 had drains.
Mohamed117 (2003)
Prospective observational
study
Newcastle-Ottawa Scale: High
39 patients with 43 chronic subdural hematomas. 0 used anticoagulants.
Managed with frontal
temporoparietal craniotomy. 39 had drains, irrigation, and bed rest.
Mortality: 0. Morbidity: 5 (transient stage of agitation and delirium
suggesting hyperperfusion
syndrome), 3 (systemic chest infection), 3 (seizure). Good
recovery: 39. Recurrence rate: 5, 2
managed with percutaneous drainage and 3 with corticosteroids.
Mori et al118 (2003)
Retrospective observational
study
Newcastle-Ottawa Scale: High
621 patients with chronic subdural hematomas. Managed with two burr
hole craniostomy. 621 had drains
and irrigation.
Mortality: 9. Morbidity: 35 (acute subdural hematoma, tension
pneumocephalus, and systemic
complications such as pneumonia).
Tagle et al119
(2003)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
100 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy.
Mortality: 3. Good recovery: 81/87.
Recurrence rate: 13.
Yamamoto et
al120 (2003)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
105 patients with 128 chronic
subdural hematomas. 4 used anticoagulants. 103 managed with
one burr hole craniostomy and 2
with two burr holes. 105 had drains and irrigation.
Recurrence rate: 11.
Zhang et al121 (2003)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
358 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 358 had drains
and irrigation.
Recurrence rate: 15, managed with burr hole. Second recurrence: 1.
Baechli et al122
(2004)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
354 patients with 432 chronic
subdural hematomas. 144 used
anticoagulants. Managed with burr hole craniostomy. 354 had drains
for 48 hours.
Mortality: 0. Recurrence rate: 48.
Second recurrence: 5.
Chen et al123
(2004)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
128 patients with 158 chronic
subdural hematomas. Managed with
burr hole craniostomy. 128 had closed system drainage.
Morbidity: 7 (seizure).
Frati et al124
(2004)
Prospective
observational study
Newcastle-Ottawa Scale:
High
35 patients with 40 chronic subdural
hematomas. 0 used anticoagulants. Managed with burr hole
craniostomy. 35 had drains for 72
hours, irrigation, and bed rest.
Morbidity: 2 (fever), 1 (infection of
skin incision). Recurrence rate: 5.
Gastone et al125
(2004)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
159 patients with 207 chronic
subdural hematomas. 38 used anticoagulants. Managed with
enlarged one burr hole craniostomy.
0 had adjuvant corticosteroids. 159 had drains and irrigation.
Mortality: 5. Morbidity: 7 (dyspnoea
due to bronchopneumonia and airway secretion accumulation, partial motor
seizures, minor pulmonary embolism,
deep vein thrombosis, and urinary infection). Good recovery: 130.
Recurrence rate: 10. Second
recurrence: 0.
Iplikçioğlu et
al126 (2004)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
22 patients with 24 chronic subdural
hematomas. Managed with burr hole craniostomy. 22 had drains.
Recurrence rate: 2, managed with
burr hole. Second recurrence: 1.
Khan et al127
(2004)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
60 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with two burr hole
craniostomy.
Mortality: 6. Morbidity: 4
(bronchopneumonia), 2 (seizure), 2 (wound infection). Good recovery:
40. Recurrence rate: 10.
Lee et al128
(2004)
Retrospective
observational
Newcastle-Ottawa Scale:
High
172 patients with chronic subdural
hematomas. 34 used anticoagulants.
Mortality: 8. Morbidity: 2 (subdural
empyema). Good recovery: 82.
13
study 38 managed with two burr hole
craniostomy, 121 with enlarged craniectomy and partial
membranectomy, and 13 with
extended craniotomy and partial membranectomy. 172 had drains for
72 hours and irrigation.
Recurrence rate: two burr holes: 6,
enlarged craniectomy with partial membranectomy: 22, extended
craniotomy with partial
membranectomy: 3, 11 managed with extended craniotomy and
membranectomy, 20 with re-opening
of the burr holes or enlarged craniectomy. Second recurrence: 1.
Dakurah et al129
(2005)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
96 patients with 107 chronic
subdural hematomas. 0 used anticoagulants. 81 managed with
one burr hole craniostomy and 15
with craniotomy. 81 had closed system drainage for 48 hours and
irrigation.
Mortality: 2. Morbidity: 3
(pneumocephalus), 1 (intracerebral hemorrhage), 2 (cerebrospinal fluid
leakage), 1 (repeated seizure). Good
recovery: 90. Recurrence rate: craniotomy: 0, burr hole: 1, managed
with craniotomy. Second recurrence:
0.
Erol et al130
(2005)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
70 patients with 77 chronic
subdural hematomas. Managed with burr hole craniostomy. 35 had
closed system drainage for 48 hours
and irrigation.
Mortality: 2 without drainage, 3 with
drainage. Morbidity: without drainage: 13 (pneumocephalus), 2
(pneumonia), 2 (urinary tract
infection), 1 (gastrointestinal bleeding), with drainage: 9
(pneumocephalus), 1 (tension
pneumocephalus), 1 (meningitis), 3 (urinary sepsis and pneumonia).
Good recovery: 29 without drainage,
27 with drainage. Recurrence rate: 6 without drainage, 5 with drainage,
managed with burr hole.
Gelabert-
González et
al131 (2005)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
1000 patients with 1097 chronic
subdural hematomas. 122 used
anticoagulants. Managed with burr hole craniostomy. 1000 had closed
system drainage and irrigation.
Mortality: 21. Morbidity: 9
(intracranial hypotension), 7
(subdural empyema), 4 (intracerebral hematoma), 2 (tension
pneumocephalus), 62 (post-operative
seizure), 22 (bronchopneumonia), 11
(cardiac problem), 8
(thromboembolic complication), 10
(septic complication). Good recovery: 979. Recurrence rate: 61. Second
recurrence: 6.
Gurunathan132 (2005)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
103 patients with chronic subdural hematomas. Managed with one burr
hole craniostomy. 0 had drains and
103 had irrigation.
Mortality: 1. Recurrence rate: 5, managed with one burr hole. Second
recurrence: 2.
Jeong et al133
(2005)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
138 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 138 had drainage
and irrigation.
Recurrence: 8, managed with burr
holes. Second recurrence: 0.
Kim et al134
(2005)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
71 patients with 83 chronic subdural
hematomas. Managed with burr
hole craniostomy. 71 had drainage.
Mortality: 1. Cure rate: 70.
Recurrence: 3, managed with burr
holes. Second recurrence: 2.
Lee et al135
(2005)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
31 patients with 43 chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 31had drainage.
Mortality: 0. Morbidity: 1 (epidural
hematoma). Cure rate: 25. Recurrence
rate: 1, managed with percutaneous drainage. Second recurrence: 0.
Miele et al136 (2005)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
44 patients with 60 chronic subdural hematomas. Managed with
percutaneous twist drill drainage. 44
had closed system drainage. 0 had irrigation.
Morbidity: 13, including 6 (pneumocephalus), 2 (acute subdural
hematoma). Good recovery: 41.
Recurrence rate: 16, 2 managed with percutaneous drainage and 14 with
14
burr hole or craniotomy. Second
recurrence: 4.
Muzii et al137
(2005)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
46 patients with 54 chronic subdural
hematomas. 12 used anticoagulants.
22 managed with percutaneous twist drill drainage and 24 with burr
hole craniostomy. 46 had closed
system drainage and 24 had irrigation.
Mortality: percutaneous drainage: 1,
burr hole: 2. Morbidity: 0 for both.
Good recovery: percutaneous drainage: 20, burr hole: 17.
Recurrence rate: percutaneous
drainage: 1, burr hole: 5, managed with burr hole. Second recurrence: 0
for both.
Stanisic et al138
(2005)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
99 patients with 121 chronic
subdural hematomas. 45 used
anticoagulants. 119 managed with one burr hole craniostomy and 2
with two burr holes. 82 had closed
system drainage for 24-48 hours and bed rest. 121 had irrigation.
Mortality: 7. Morbidity: 1 (superficial
wound infection), 3 (subdural
empyema). Good recovery: 100. Recurrence rate: 18, 13 managed with
repeated evacuation and flushing
through the previous burr hole, 3 with second burr hole, and 2 with
craniotomy. Second recurrence: 2.
Sun et al139 (2005)
Prospective observational
study
Newcastle-Ottawa Scale: High
112 patients with chronic subdural hematomas. 5 used anticoagulants.
26 managed with dexamethasone,
82 with burr hole craniostomy, and 4 conservatively. 69/82 had
adjuvant corticosteroids. 0 had drains and bed rest. 82 had
irrigation.
Mortality: dexamethasone group: 1, burr hole: 2 with adjuvant
dexamethasone, 2 without
dexamethasone, conservative: 2. Morbidity: dexamethasone group: 1
(subarachnoid hemorrhage), burr hole: with dexamethasone: 1 (urinary
tract and chest infection), 1
(intracerebral hemorrhage), without dexamethasone: 1 (chest infection), 1
(carcinoma of rectum), conservative:
1 (liver failure), 1 (deterioration in general condition). Good recovery:
dexamethasone group: 23, burr hole:
63 with adjuvant dexamethasone, 10 without dexamethasone,
conservative: 2. Recurrence rate:
dexamethasone group: 1, burr hole: 3
with adjuvant dexamethasone, 2
without dexamethasone,
conservative: 2, managed with burr hole.
Bozkurt et al140
(2006)
Prospective
observational study
Newcastle-Ottawa Scale:
High
20 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage. 0
had drains and 20 had irrigation.
Mortality: 0. Morbidity: 0.
Recurrence rate: 7, managed with percutaneous drainage. Second
recurrence: 2.
Horn et al141
(2006)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
79 patients with chronic subdural
hematomas. 55 managed with
percutaneous twist drill drainage and 24 with burr hole craniostomy.
79 had drains and 55 had irrigation.
Mortality: percutaneous drainage: 4,
burr hole: 3. Morbidity: percutaneous
drainage: 3 (acute subdural hematoma), 2 (respiratory failure), 1
(myocardial failure), 1 (seizure), 1
(sepsis), burr hole: 1 (reoperation for wound revision), 1 (acute subdural
hematoma), 1 (stroke). Good
recovery: percutaneous drainage: 46, burr hole: 18. Recurrence rate:
percutaneous drainage: 12, burr hole:
3.
Takeda et al142
(2006)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
70 patients with 78 chronic subdural
hematomas. 15 used anticoagulants. Managed with percutaneous twist
drill drainage. 0 had drains,
irrigation, and bed rest.
Morbidity: 1 (acute subdural
hematoma). Good recovery: 70. Recurrence rate: 7, managed with
percutaneous drainage. Second
recurrence: 3.
Wada et al143 Retrospective Newcastle-Ottawa Scale: 34 patients with chronic subdural Recurrence rate: 1.
15
(2006) observational
study
Low hematomas. 10 used anticoagulants.
Managed with one burr hole craniostomy. 34 had closed system
drainage and irrigation.
Xie et al144 (2006)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
84 patients with chronic subdural hematomas. 69 patients managed
with burr holes and 15 with
craniotomy.
Mortality: burr: 0, craniotomy: 1. Cure rate: burr: 65, craniotomy: 14.
Recurrence: burr: 4, craniotomy: 0.
Second recurrence: 0.
Abouzari et
al145 (2007)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
84 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with one burr hole
craniostomy. 84 had drains for 48
hours and irrigation. 42 had bed rest for 72 hours.
Morbidity: bed rest: 10 (atelectasis), 5
(pneumonia), 3 (decubitus ulcer), no bed rest: 7 (atelectasis), 4
(pneumonia), 2 (decubitus ulcer), 1
(deep vein thrombosis). Recurrence rate: 1 (bed rest), 8 (no bed rest).
Amirjamshidi
et al146 (2007)
Prospective
observational study
Newcastle-Ottawa Scale:
High
82 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with one burr hole
craniostomy. 82 had closed system
drainage for 24-48 hours and irrigation.
Mortality: 2. Good recovery: 60.
Recurrence rate: 10, managed with one burr hole.
Amirjamshidi et al147 (2007)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
116 patients with chronic subdural hematomas. 0 used anticoagulants.
Managed with one burr hole
craniostomy. 116 had closed system drainage for 24-48 hours and
irrigation.
Good recovery: 92.
Gazzeri et al148
(2007)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
224 patients with 251 chronic
subdural hematomas. 14 used
anticoagulants. Managed with one burr hole craniostomy. 224 had
drainage with a Jackson pratt drain
in the subgaleal space with the suction facing the burr hole for 48-
72 hours. 224 had irrigation and bed
rest.
Mortality: 2. Morbidity: 1 (subgaleal
empyema), 2 (partial motor seizure),
2 (pneumonia), 1 (acute subdural hematoma/multi-organ failure).
Recurrence rate: 17, managed with
one burr hole. Second recurrence: 0.
Gurelik et al149
(2007)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
80 patients with chronic subdural
hematomas. 42 managed with burr
hole craniostomy and 38 with percutaneous twist drill drainage. 80
had closed system drainage for 48
hours and irrigation.
Recurrence rate: burr hole: 8,
percutaneous drainage: 4.
Kang et al150
(2007)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
302 patients with 337 chronic
subdural hematomas. Managed with one burr hole craniostomy. 302 had
closed-system drainage for 48 hours
with a silicon catheter and bag.
Recurrence rate: 24, managed with
one burr hole.
Kiymaz et al151
(2007)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
50 patients with chronic subdural
hematomas. 1 used anticoagulants. Managed with two burr hole
craniostomy. 29 had drains. 50 had
irrigation and bed rest.
Recurrence rate: 8 (2 with drainage, 6
without drainage).
Maarrawi et
al152 (2007)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
154 patients with 199 chronic
subdural hematomas. 109 managed
with burr hole craniostomy and 45 with percutaneous twist drill
drainage. 0 had adjuvant
corticosteroids. 154 had closed system drainage for 24 hours and
109 had irrigation.
Mortality: burr hole: 1, percutaneous
drainage: 0. Morbidity: burr hole: 1
(meningitis), 4 (severe pneumocephalus), 6 (seizure), 2
(intracerebral hematoma), 2
(hygroma), percutaneous drainage: 1 (seizure). Good recovery: burr hole:
107, percutaneous drainage: 45.
Recurrence rate: burr hole: 15,
16
percutaneous drainage: 1, 13
managed with trephination, 2 with craniotomy, and 1 with percutaneous
drainage.
Santos-Ditto et al153 (2007)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
213 patients with chronic subdural hematomas. Managed with
percutaneous twist drill drainage.
Morbidity: 19. Good recovery: 208. Recurrence rate: 17, managed with
percutaneous drainage. Second
recurrence: 0.
Sucu et al154
(2007)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
39 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage. 39
had drains.
Morbidity: 1 (brain penetration), 1
(inability to penetrate the dura mater with the drill), 1 (epidural
hematoma), 3 (catheter folding).
Recurrence rate: 1, managed with burr hole.
Tokmak et al155
(2007)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
24 patients with 27 chronic subdural
hematomas. 0 used anticoagulants. Managed with burr hole
craniostomy. 24 had drains for 72-
96 hours.
Recurrence rate: 1, managed with
burr hole.
Weigel et al156
(2007)
Prospective
observational study
Newcastle-Ottawa Scale:
High
310 patients with chronic subdural
hematomas. Managed with burr hole craniostomy. 310 had closed
system drainage and irrigation.
Recurrence rate: 46.
Gökmen et al157
(2008)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
70 patients with chronic subdural
hematomas. 38 managed with
percutaneous twist drill drainage and 32 with one burr hole
craniostomy. 70 had drainage for 48
hours and 32 had irrigation.
Mortality: percutaneous drainage: 1,
burr hole: 1. Morbidity: burr hole: 0,
percutaneous drainage: 1 (temporary sixth nerve paresis), 1 (epidural
hematoma), 1 (inability to perforate
the dura), 2 (kinking of the drain). Good recovery: burr hole: 26,
percutaneous drainage: 29.
Recurrence rate: burr hole: 2, percutaneous drainage: 1.
Guzel et al158
(2008)
Prospective
observational study
Newcastle-Ottawa Scale:
High
20 patients with 24 chronic subdural
hematomas. Managed with one burr hole craniostomy. 20 had closed
system drainage for 42-72 hours
and irrigation.
Mortality: 1. Morbidity: 0. Good
recovery: 20. Recurrence rate: 0.
Khadka et al159
(2008)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
365 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 117 had adjuvant
corticosteroids. 0 had drains. 365
had bed rest for 48 hours and irrigation.
Mortality: 5. Morbidity: 4 (superficial
wound infection), 1 (subdural empyema), 1 (intracerebral
hematoma). Good recovery: 360.
Recurrence rate: 17, managed with one burr hole. Second recurrence: 0.
Ko et al160 (2008)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
255 patients with 277 chronic subdural hematomas. 8 used
anticoagulants. Managed with one
burr hole craniostomy. 255 had closed system drainage for 48 hours
and bed rest. 0 had irrigation.
Recurrence rate: 24, managed with one burr hole. Second recurrence: 3
Kristof et al161 (2008)
Prospective observational
study
Newcastle-Ottawa Scale: High
67 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 67 had closed
system drainage and irrigation.
Recurrence rate: 13.
Park et al162
(2008)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
24 patients with 36 chronic subdural
hematomas. 6 used anticoagulants. Managed with burr hole
craniostomy. 24 had irrigation.
Mortality: 1. Morbidity: 1
(myocardial infarction). Good recovery: 23. Recurrence rate: 3.
17
Ramnarayan et
al163 (2008)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
42 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with percutaneous twist
drill drainage. 42 had closed system
drainage. 0 had bed rest.
Mortality: 2. Morbidity: 1
(myocardial infarction), 1 (pneumonia), 1 (seizure). Good
recovery: 37.
Schebesch et
al164 (2008)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
356 patients with 441 chronic
subdural hematomas. 343 managed
with burr hole craniostomy.
Morbidity: 12 (seizure).
Secer et al165
(2008)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
45 patients with 57 chronic subdural
hematomas. Managed with two burr hole craniostomy. 45 had drainage
and irrigation.
Mortality: 6. Morbidity: 0. Cure rate:
33. Recurrence: 8, 6 managed with craniotomy and 2 with burr holes.
Second recurrence: 0.
Taussky et al166 (2008)
Retrospective observational
study
Newcastle-Ottawa Scale: High
76 patients with 97 chronic subdural hematomas. 53 used anticoagulants.
34 managed with one burr hole
craniostomy and 63 with two burr holes. 97 had closed system
drainage for 48 hours, bed rest, and
irrigation.
Mortality: 1 (one burr hole). Morbidity: 3 (wound infection), 3 for
one burr, 0 for two burr holes.
Recurrence rate: 13 (10 one burr hole, 3 two burr holes), 8 managed with
burr hole, 5 with subduroperitoneal
shunt. Second recurrence: 5.
Torihashi et
al167 (2008)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
337 patients with 406 chronic
subdural hematomas. 62 used anticoagulants. Managed with one
burr hole craniostomy. 337 had
irrigation.
Mortality: 0. Morbidity: 0.
Recurrence rate: 61. Second recurrence: 12.
Zakaraia et al168
(2008)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
89 patients with 92 chronic subdural
hematomas. 0 used anticoagulants. 40 managed with two burr hole
craniostomy and 42 with one burr
hole. 82 had closed system drainage for 72 hours. 40 had irrigation.
Mortality: 0. Morbidity: 5. Good
recovery: 35 (two burr holes), 35 (one burr hole). Recurrence rate: 4 (two
burr holes), 6 (one burr hole), 4
managed with two burr holes and 6 with one burr hole.
Abouzari et
al169 (2009)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
300 patients with chronic subdural
hematomas. 3 used anticoagulants. Managed with burr hole
craniostomy.
Good recovery: 228.
Akhaddar et
al170 (2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
110 patients with 141 chronic
subdural hematomas. 13 used
anticoagulants. Managed with burr hole craniostomy. 110 had drains.
Mortality: 2. Morbidity: 3
(intraparenchymal hematoma), 1
(epidural hematoma), 2 (subdural empyema and severe pneumonia).
Good recovery: 99. Recurrence rate:
8. Second recurrence: 1.
Delgado-López
et al171 (2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
122 patients with 166 chronic
subdural hematomas. 22 used
anticoagulants. 15 managed with percutaneous twist drill drainage, 4
with craniotomy, 101 with dexamethasone, and 2
conservatively. 0 had adjuvant
corticosteroids. 15 had closed system drainage for 48-72 hours. 0
had irrigation. 101 had bed rest.
Mortality: percutaneous drainage: 0,
craniotomy: 0, dexamethasone: 1,
conservative: 0. Good recovery: percutaneous drainage: 14,
craniotomy: 3, dexamethasone: 97, conservative: 2. Recurrence rate:
percutaneous drainage: 2,
dexamethasone: 22, conservative: 0, managed with percutaneous drainage.
Second recurrence: percutaneous
drainage: 0, dexamethasone: 3,
conservative: 0.
Grobelny et
al172 (2009)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
88 patients with chronic subdural
hematomas. Managed with burr hole craniostomy.
Morbidity: 6 (seizure).
Han et al173 (2009)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
180 patients with 205 chronic subdural hematomas. Managed with
51 one burr hole craniostomy and
129 two burr holes. 180 had closed
Recurrence rate: 1 (one burr hole), 9 (two burr holes), 1 managed with one
burr hole and 9 with two burr holes.
18
system drainage for 120 hours,
irrigation, and bed rest.
Hong et al174
(2009)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
66 patients with 77 chronic subdural
hematomas. 0 used anticoagulants.
Managed with burr hole craniostomy. 66 had drains for 72
hours and irrigation.
Recurrence: 14, managed by 10 one
burr hole, 3 additional burr hole, 1
craniotomy.
Hwang et al175
(2009)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
30 patients with 35 chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 30 had closed system drainage and bed
rest for 24 hours.
Mortality: 0. Morbidity: 0. Good
recovery: 30. Recurrence rate: 1,
managed with percutaneous drainage. Second recurrence: 0.
Ishfaq et al176 (2009)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
60 patients with 69 chronic subdural hematomas. Managed with 47 one
burr hole craniostomy and 13 with
two burr holes. 60 had closed system drainage and bed rest.
Morbidity: 7 (weakness of the contralateral limbs), 3 (wound
infection), 5 (seizure). Good
recovery: 51. Recurrence rate: 7, managed with repeated burr hole.
Second recurrence: 1.
Lee et al177
(2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
87 patients with chronic subdural
hematomas. Managed with 25 one
burr hole craniostomy, 32 with two burr holes, and 30 with small
craniotomy. 87 had closed system
drainage and 75 had irrigation.
Morbidity: one burr hole: 4
complications such as (wound
infection, decreased mentality, hemothorax, pneumonia), two burr
holes: 4 (partial seizure attack,
general tonic clonic seizure attack, pneumonia, hematochezia, left side
motor weakness), craniotomy: 1
(pneumonia). Recurrence rate: one burr hole: 6, two burr holes: 7,
craniotomy: 2.
Lindvall et al178
(2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
71 patients with 88 chronic subdural
hematomas. 22 used anticoagulants.
59 managed with burr hole craniostomy, 7 with craniotomy,
and 5 conservatively. 66 had closed
system drainage with a subdural catheter connected to a plastic bag
with the bag placed at bed level for
24-48 hours. 59 had irrigation.
Mortality: 1. Morbidity: 11
(neurological deficits, decreased level
of consciousness, or severe headache), 1 (subdural empyema).
Good recovery: 70. Recurrence rate:
burr hole: 10, craniotomy: 1, conservative: 0, 8 managed with burr
hole and 3 with craniotomy. Second
recurrence: 0.
Mondorf et
al179 (2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
193 patients with 222 chronic
subdural hematomas. 78 used
anticoagulants. 151 managed with craniotomy and 42 with burr hole
craniostomy. 190 had low vacuum
suction reservoir drainage for maximum 72 hours. 193 had
irrigation.
Mortality: craniotomy: 7, burr hole:
1. Morbidity: 14 (postoperative
seizure). Good recovery: craniotomy: 104, burr hole: 36. Recurrence rate:
craniotomy: 42, burr hole: 6.
Radisavljevic
et al180 (2009)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
93 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 93 had drainage for 48 hours, irrigation, and bed
rest.
Recurrence rate: 6, managed with one
burr hole. Second recurrence: 1.
Santarius et
al181 (2009)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
215 patients with chronic subdural
hematomas. 21 used anticoagulants
(with drain), 28 antiplatelets (with drain), 18 anticoagulants (without
drain), and 36 antiplatelets (without
drain). 215 managed with two burr hole craniostomy. 108 had drains
for 48 hours. 215 had irrigation.
Mortality: 4 (with drainage), 8
(without drainage). Morbidity: 3
subdural empyemas (1 with drainage, 2 without drainage), 1 intracerebral
hematoma (without drainage), 1 acute
subdural hematoma (without drainage), 5 pneumonias (3 with
drainage, 2 without drainage), 2 renal
failures (1 each), 2 urinary tract infections (1 each), 1 myocardial
19
infarction (with drainage), 1 atrial
fibrillation (without drainage), 1 gastritis (without drainage). Good
recovery: 81 out of 97 (with
drainage), 64 out of 95 (without drainage). Recurrence rate: 10 (with
drainage), 26 (without drainage).
Shimamura et al182 (2009)
Randomized trial
See results of the Cochrane risk of bias assessment tool
79 patients with 97 chronic subdural hematomas. 54 used anticoagulants.
Managed with one burr hole
craniostomy. 79 had closed system drainage for 24 hours and irrigation.
Recurrence rate: 13.
Yu et al183 (2009)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
97 patients with 121 chronic subdural hematomas. Managed with
one burr hole craniostomy. 97 had
closed system drainage, irrigation, and bed rest.
Mortality: 2. Morbidity: 1 (minor skin incision infection). Recurrence rate:
8.
Zumofen et
al184 (2009)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
147 patients with 183 chronic
subdural hematomas. 37 used antiplatelets. Managed with two
burr hole craniostomy. 147 had
subperiostal/extracranial passive draining system for 48 hours. 147
had irrigation and bed rest.
Mortality: 5. Morbidity: 2 (acute
bleeding), 1 (epidural bleeding), 1 (cardiac arrest), 1 (severe
atelectasis/cardiopulmonary failure),
2 (superficial wound infection), 1 (deep wound infection/subdural
empyema), 12 (postoperative seizure). Good recovery: 108.
Recurrence rate: 22, 15 managed with
second trephination, 2 with craniotomy, and 5 conservatively.
Ibrahim et al185
(2010)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
65 patients with chronic subdural
hematomas. 26 used anticoagulants (15 in 48 hours group, 11 in 96
hours group). Managed with
percutaneous twist drill drainage. 65 had drains and bed rest (35 in 48
hour group, 30 in 96 hours group).
Mortality: 5 (1 in 48 hours drainage,
4 in 96 hours drainage). Morbidity: 3 (2 from neurologic and 1 from
general complication [urinary
infection] in 48 hours), 9 (2 from neurologic and 7 from general
complications [1 urinary infection, 3
respiratory infections, 1 dehydration, 1 insufficient poly-visceral, 1 inferior
membrane infection] in 96 hours).
Good recovery: 30 (48 hours drainage), 25 (96 hours drainage).
Recurrence rate: 4 (48 hours
drainage), 3 (96 hours drainage).
Kanat et al186
(2010)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
76 patients with chronic subdural
hematomas. Managed with burr hole craniostomy.
Mortality: 2. Recurrence rate: 3.
Kansal et al187 (2010)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
267 patients with chronic subdural hematomas. 0 used anticoagulants.
195 managed with one burr hole
craniostomy and 72 with two burr holes. 0 had adjuvant
corticosteroids and drains. 267 had
irrigation and bed rest.
Recurrence rate: 26 (one burr hole), 6 (two burr holes), 26 managed with
one burr hole and 6 with two burr
holes.
Kenning et al188
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
74 patients with 85 chronic subdural
hematomas. 45 used anticoagulants.
Managed with percutaneous twist drainage. 74 had subdural
evacuating port drainage system.
Morbidity: 2 (acute postoperative
hemorrhage). Recurrence rate: 22, 1
managed with burr hole and 21 with craniotomy. Second recurrence: 1.
Kurabe et al189
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
182 patients with 216 chronic
subdural hematomas. 38 used
anticoagulants (15 with bed rest, 23 without bed rest). Managed with
Morbidity: with bed rest: 1
(arrhythmia), 4 (pneumonia), 2
(ileus), 2 (pseudomembranous colitis), 4 (constipation), 6 (urinary
20
one burr hole craniostomy. 182 had
closed system drainage for 48 hours (with bed rest) and same day as
operation (without bed rest).
tract infection), 2 (seizure), 3
(eruption), without bed rest: 1 (arrhythmia), 1 (pneumonia), 2
(constipation), 1 (urinary tract
infection), 1 (cerebral infarction), 2 (seizure). Recurrence rate: 14 (6 with
bed rest, 8 without bed rest). Second
recurrence: 1.
Liu et al190
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
398 patients with 492 chronic
subdural hematomas. 6 used
anticoagulants. Managed with burr hole craniostomy. 398 had drains
and irrigation.
Mortality: 1. Morbidity: 1 (subdural
abscess), 3 (pneumonia). Good
recovery: 380. Recurrence rate: 15.
Mino et al191
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
75 patients with chronic subdural
hematomas. Managed with one burr
hole craniostomy.
Recurrence rate: 4
Nagashima et
al192 (2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
172 patients with chronic subdural
hematomas. Managed with one burr
hole craniostomy.172 had closed system drainage.
Recurrence rate: 23.
Oh et al193 (2010)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
149 patients with chronic subdural hematomas. 143 managed with one
burr hole craniostomy, 3 with two
burr holes, and 3 with craniotomy. 149 had drainage for 48 hours.
Good recovery: 131. Recurrence rate: craniotomy: 0, burr hole: 18, 11
managed with one burr hole and
bilateral burr holes. 7 were managed conservatively and their chronic
subdural hematoma resolved
spontaneously. Second recurrence: 4.
Rehman et al194
(2010)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
60 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with two burr hole
craniostomy. 0 had drains and 60
had irrigation.
Mortality: 4. Morbidity: 2
(pneumocephalus), 2 (intracerebral hemorrhage), 4 (chest infection), 4
(seizure). Good recovery: 52.
Recurrence rate: 4.
Rughani et al195
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
42 patients with 54 chronic subdural
hematomas. 17 used anticoagulants.
21 managed with percutaneous twist drill drainage and 21 with burr
hole craniostomy. 21 had subdural
evacuating port drainage system and 21 had ventriculostomy catheter
drainage. 21 had irrigation.
Mortality: percutaneous drainage: 2,
burr hole: 1. Morbidity: percutaneous
drainage: 0 (infection), 1 (acute hemorrhage), 1 (seizure), burr hole: 0
(infection), 0 (acute hemorrhage), 1
(seizure). Recurrence rate: percutaneous drainage: 5, burr hole:
3.
Santarius et
al196 (2010)
Retrospective observational
study
Newcastle-Ottawa Scale:
High
408 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 408 had drains for 48 hours and irrigation.
Recurrence rate: 64, 1 managed with
craniotomy and 63 with burr hole.
Second recurrence: 15.
Senturk et al197 (2010)
Retrospective observational
study
Newcastle-Ottawa Scale: High
34 patients with 48 chronic subdural hematomas. Managed with burr
hole craniostomy. 34 had irrigation.
Mortality: 1. Morbidity: 1 (adult respiratory distress syndrome). Good
recovery: 33. Recurrence rate: 0.
Tsai et al198 (2010)
Retrospective observational
study
Newcastle-Ottawa Scale: High
129 patients with 174 chronic subdural hematomas. 11 used
anticoagulants. Managed with burr
hole craniostomy. 129 had closed system drainage with no suction and
irrigation.
Mortality: 11. Morbidity: 0 (tension pneumocephalus), 25 (seizure), 4
(infection), 3 (hydrocephalus), 2
(acute subdural hematoma). Good recovery: 117. Recurrence rate: 12.
White et al199
(2010)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
246 patients with chronic subdural
hematomas. 82 used anticoagulants.
130 managed with burr hole craniostomy and 116 with
minicraniotomy. 4 had drains.
Mortality: burr hole: 10, craniotomy:
20. Morbidity: burr hole: 2 (subdural
empyema), 12 (seizure), craniotomy: 3 (subdural empyema), 10 (seizure).
Good recovery: burr hole: 64 out of
77, craniotomy: 66 out of 90.
21
Recurrence rate: burr hole: 23,
craniotomy: 23.
Bankole et al200
(2011)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
73 patients with 95 chronic subdural
hematomas. 2 used anticoagulants.
70 managed with one burr hole craniostomy and 3 with craniotomy.
73 had closed system drainage for
48 hours and irrigation.
Mortality: 3/48. Morbidity: 2/48
(seizure), 1/48 (intracerebral
hematoma), 1/48 (pneumocephalus), 1/48 (urinary retention). Good
recovery: 44/48. Recurrence rate:
6/48.
Carlsen et al201
(2011)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
344 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 206 had drainage
from the subgaleal space or
subdural space for 24 hours and irrigation.
Mortality: 2 (1 with drainage, 1
without drainage). Morbidity: 5 (acute subdural hematoma) 2 with
drainage, 3 without drainage.
Recurrence rate: 65 (29 with drainage), (36 without drainage).
Escosa Baé et
al202 (2011)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
312 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage.
312 had adjuvant corticosteroids. 0
had irrigation. 312 had drains for 8-48 hours and bed rest.
Mortality: 3. Morbidity: 22 (local
hematoma), 3 (acute subdural hematoma), 5 (brain damage). Good
recovery: 256. Recurrence rate: 37.
Hazra et al203 (2011)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
188 patients with chronic subdural hematomas. Managed with burr
hole craniostomy and middle
meningeal artery embolization for refractory hematomas. 188 had
irrigation.
Recurrence rate: 13, managed with burr hole. Second recurrence: 2.
Huang et al204
(2011)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
100 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy. 100 had closed system drainage and irrigation.
Mortality: 2. Morbidity: 3
(pneumonia), 3 (urinary tract
infection), 11 (seizure). Good recovery: 95. Recurrence rate: 39,
managed with craniotomy.
Ishibashi et al205 (2011)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
92 patients with 101 chronic subdural hematomas. 16 used
anticoagulants. Managed with one
burr hole craniostomy. 92 had closed system drainage with a
collection bag for 24-48 hours. 34
had irrigation and 92 had bed rest.
Mortality: 2 (drainage), 0 (drainage with irrigation). Good recovery: 48
(drainage), 34 (drainage with
irrigation). Recurrence rate: 6 (drainage), 1 (drainage with
irrigation).
Javadi et al206
(2011)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
40 patients with chronic subdural
hematomas. 9 used antiplatelets. Managed with two burr hole
craniostomy. 20 had closed system
bag drainage adjusted at the level of patient's head without negative
pressure for 48 hours and 40 had
irrigation.
Mortality: 4 (with drainage), 2
(without drainage). Morbidity: 4 with drainage: 2 (deep vein thrombosis), 1
(acute subdural hematoma), 1 (renal
failure), 2 without drainage: 1 (aspiration pneumonia), 1 (tension
pneumocephalus and status
epilepticus). Good recovery: 12 (with drainage), 10 (without drainage).
Recurrence rate: 1 (with drainage), 1
(without drainage), managed with two burr holes.
Kaiser et al207
(2011)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
180 patients with 201 chronic
subdural hematomas. Managed with
burr hole craniostomy. 180 had
irrigation.
Mortality: 1. Recurrence rate: 27.
Kim et al208
(2011)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
317 patients with chronic subdural
hematomas. 259 managed with burr
hole craniostomy, 16 with small craniotomy (3-4 cm diameter) and
partial membranectomy, and 42
with large craniotomy (diameter of
Mortality: burr hole: 21, small
craniotomy: 0, extended craniotomy:
2. Morbidity: burr hole: 9 (local postoperative complications such as
surgical wound infection, tension
pneumocephalus, epidural hematoma,
22
hematoma) and extended
membranectomy. 259 had closed system drainage for 48-72 hours.
and seizure), 29 (systemic
complications such as pneumonia and sepsis), small craniotomy: 1 (local
postoperative complication), 1
(systemic complication), extended craniotomy: 2 (local postoperative
complication), 2 (systemic
complication). Good recovery: burr hole: 202, small craniotomy: 7,
extended craniotomy: 17. Recurrence
rate: burr hole: 23, small craniotomy: 8, extended craniotomy: 4, 25
managed with repeated burr hole and
10 with large craniotomy.
Lin209
(2011)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
448 patients with 552 chronic
subdural hematomas. 178 managed
with percutaneous twist drill drainage and 270 with one burr hole
craniostomy. 44 had closed system
drainage for average of 72 hours and 270 had irrigation.
Mortality: percutaneous drainage: 4,
burr hole: 4. Morbidity: percutaneous
drainage: 0, burr hole: 4 (infection), 6 (tension pneumocephalus), 5 (brain
injury), 9 (seizure). Good recovery:
percutaneous drainage: 158, burr hole: 204. Recurrence rate:
percutaneous drainage: 14, burr hole:
32, 36 managed with percutaneous drainage and 10 with one burr hole.
Mezue et al210 (2011)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
246 patients with chronic subdural hematomas. 19 used antiplatelets.
Managed with burr hole
craniostomy. 246 had drains.
Mortality: 2. Good recovery: 214. Recurrence rate: 19, managed with
burr hole.
Miranda et al211
(2011)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
209 patients with 264 chronic
subdural hematomas. 81 used antiplatelets. 21 managed with two
burr hole craniostomy, 44 with
percutaneous twist drill drainage, 72 with craniotomy, and 72
conservatively. 137 had closed
system drainage for 24-72 hours
and 21 had irrigation.
Mortality: 35. Good recovery: 145.
Recurrence rate: two burr holes: 1, percutaneous drainage: 4,
craniotomy: 0, conservative: 0,
managed with craniotomy.
Mostofi et al212
(2011)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
28 patients with 29 chronic subdural
hematomas. 13 used anticoagulants. Managed with percutaneous twist
drill drainage. 0 had adjuvant
corticosteroids. 28 had bed rest.
Mortality: 0. Morbidity: 0. Good
recovery: 27. Recurrence rate: 1.
Park et al213
(2011)
Prospective observational study
Newcastle-Ottawa Scale:
High
31 patients with chronic subdural
hematomas. 0 used anticoagulants. Managed with burr hole
craniostomy. 31 had adjuvant
dexamethasone, drainage, and irrigation.
Good recovery: 31. Recurrence rate:
1.
Sarnvivad et al214 (2011)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
143 patients with chronic subdural hematomas. 63 used anticoagulants.
Managed with burr hole
craniostomy. 97 had drainage and 143 had irrigation.
Mortality: 2 (drainage), 1 (without drainage). Morbidity: 2 (drainage), 1
(without drainage). Good recovery:
79 (drainage), 32 (without drainage). Recurrence rate: 15 (drainage), 12
(without drainage).
Singh et al215 (2011)
Randomized trial
See results of the Cochrane risk of bias assessment tool
100 patients with chronic subdural hematomas. 48 managed with
percutaneous twist drill drainage
and 52 with two burr holes craniostomy. 100 had drainage and
irrigation.
Mortality: percutaneous: 2, burr: 0. Morbidity: percutaneous: 1 (wound
infection), 5 (hematoma formation), 1
(meningitis), burr: 3 (wound infections), 4 (subdural hemorrhage
or parenchymal contusion) in 49
patients. Cure rate: percutaneous: 42, burr: 49. Recurrence: percutaneous:
23
4, burr: 1.
Adeolu et al216 (2012)
Prospective observational
study
Newcastle-Ottawa Scale: High
50 patients with 62 chronic subdural hematomas. Managed with burr
hole craniostomy. 50 had bed rest.
Morbidity: 1 (infection), 1 (pnemocephalus). Good recovery: 45.
Recurrence rate: 0.
Bellut et al217
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
113 patients with 143 chronic
subdural hematomas. 11 used oral
anticoagulation (subperiosteal drainage), 17 antiplatelets
(subperiosteal), 18 oral
anticoagulation (subdural), and 16 antiplatelets (subdural). 113
managed with two burr hole
craniostomy. 48 had subperiosteal drainage and 65 had subdural for 48
hours. 113 had irrigation and bed
rest.
Mortality: 1 (subdural). Morbidity:
overall 25 periosteal & 39 subdural,
subperiosteal: 3 (clinical remnant), 12 (urinary tract infection), 3
(pneumonia), 6 (others), 5 (paresis), 2
(aphasia), 6 (headaches), 21 (physical imbalance), 1 (seizure), 9 (acute
states of confusion), subdural: 1
(clinical remnant), 4 (intracerebral hematoma), 14 (urinary tract
infection), 9 (pneumonia), 9 (others),
9 (paresis), 7 (aphasia), 15 (headache), 16 (physical imbalance),
4 (seizure), 10 (acute states of
confusion). Good recovery: 18 (subperiosteal), 26 (subdural).
Recurrence rate: 1 (subperiosteal), 2
(subdural).
Berghauser
Pont et al218 (2012)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
496 patients with 613 chronic
subdural hematomas. 262 used anticoagulants. 382 managed with
two burr hole craniostomy and 114
with one burr hole. 496 had adjuvant corticosteroids and
irrigation. 440 had closed system
drainage for maximum 48 hours and bed rest.
Mortality: 26. Morbidity: 52 (urinary
tract and/or pulmonary infection), 9 (deep venous/pulmonary embolism),
14 (subdural empyema), 4 (post-
operative wound infection). Recurrence rate: 59.
Borger et al219
(2012)
Retrospective observational study
Newcastle-Ottawa Scale:
High
322 patients with 399 chronic
subdural hematomas. 162 used anticoagulants. Managed with one
burr hole craniostomy. 399 had
closed system drainage and irrigation.
Mortality: 11. Morbidity: 5
(intracerebral hemorrhage), 9 (acute subdural hematoma), 5 (epidural
hematoma), 3 (cerebral infarction), 2
(infection). Good recovery: 289. Recurrence rate: 89.
Chon et al220 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
420 patients with 488 chronic subdural hematomas. 34 used
anticoagulants and 117 used
antiplatelets. Managed with one burr hole craniostomy. 0 had
adjuvant corticosteroids. 420 had closed system drainage maintained 50 cm below head level for 72
hours and irrigation.
Morbidity: 1 (epidural hematoma), 1 (intracerebral hemorrhage), 8
(infection). Recurrence rate: 92.
Second recurrence: 12.
de Araujo Silva
et al221 (2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
125 patients with 144 chronic
subdural hematomas. Managed with
burr hole craniostomy. 117 had drainage and 125 had irrigation.
Mortality: 14. Morbidity: 3 (wound
infections). Cure rate: 103. recurrence
rate: 11.
Ducruet et al222
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
77 patients with chronic subdural
hematomas. Managed with burr
hole craniostomy.
Mortality: 1. Good recovery: 58.
Janowski et al223 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: High
45 patients with 48 chronic subdural hematomas. Managed with two burr
hole craniostomy. 44 had drains for
24 hours.
Mortality: 0. Morbidity: 0. Good recovery: 42. Recurrence rate: 7,
managed with two burr holes. Second
recurrence: 0.
Kaliaperumal
et al224 (2012)
Randomized
trial
See results of the Cochrane
risk of bias assessment tool
50 patients with 60 chronic subdural
hematomas. 25 used anticoagulants.
Managed with two burr hole
Mortality: 1. Morbidity: 2 (1 seizure
and 1 intraparenchymal placement of
a drain). Recurrence rate: 0.
24
craniostomy. 50 had drains (25
subdural and 25 periosteal) and irrigation.
Khan225
(2012)
Retrospective
observational study
Newcastle-Ottawa Scale:
Low
47 patients with 57 chronic subdural
hematomas. Managed with two burr hole craniostomy. 47 had subdural
drainage.
Mortality: 4. Good recovery: 34.
Kitazono et
al226 (2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
Low
26 patients with 34 chronic subdural
hematomas. Managed with one burr
hole craniostomy. 26 had irrigation.
Recurrence: 2.
Kong et al227
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
136 patients with 157 chronic
subdural hematomas. 32 managed
with one burr hole craniostomy and 104 with two burr hole
craniostomy. 136 had drainage and
irrigation.
Mortality: 0. Cure rate: 124.
Recurrence rate: 12.
Krieg et al228
(2012)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
320 patients with chronic subdural
hematomas. 183 used anticoagulants. Managed with
hallow screw placement. 320 had
closed system drainage and irrigation.
Mortality: 5. Morbidity: 1 (epidural
hematoma), 5 (meningitis), 53 (bladder infection), 26 (seizure), 15
(pneumonia), 5 (stroke), 3
(pulmonary embolism), 2 (thrombosis). Good recovery: 257.
Recurrence rate: 117, 52 managed
with hollow screw placement, 65 with burr hole, and 1 with craniotomy.
Latini et al229 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
127 patients with 163 chronic subdural hematomas. 6 used
anticoagulants. 116 managed with
trans-marrow puncture. 116 had closed system drainage.
Mortality: 6. Morbidity: 2 (respiratory infection), 1 (heart
disease), 1 (coagulopathy), 1
(intracranial hemorrhage), 1 (general deterioration/sepsis). Recurrence rate:
50, managed with trans-marrow
puncture. Second recurrence: 10.
Lee et al230
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
134 patients with 151 chronic
subdural hematomas. Managed with
percutaneous twist drill drainage. 134 had drainage and 0 had
irrigation.
Morbidity: 2. Cure rate: 114.
Recurrence rate: 8, 7 managed with
burr holes and 1 with percutaneous drainage.
Nayil et al231
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
1181 patients with 1347 chronic
subdural hematomas. 23 used
anticoagulants. Managed with two burr hole craniostomy. 1305/1347
procedures had subdural space
drainage for 48 hours. 1181 had irrigation and bed rest.
Mortality: 26. Morbidity: 5 (acute
subdural hematoma), 1 (acute
epidural hematoma), 1 (large thalamic hematoma), 8 (seizure), 9 (empyema).
Good recovery: 733/1013.
Recurrence rate: 43 (ipsilateral), 14 (opposite side), 43 managed with
reopening of the pervious burr hole
and 14 with two burr holes. Second recurrence: 9.
Neal et al232 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
159 patients with 171 chronic subdural hematomas. 150 used
anticoagulants. 159 managed with
percutaneous twist drill drainage.
159 had hermatically sealed
drainage for 24 hours and 0 had
irrigation.
Good recovery: 129. Recurrence rate: 30.
Neils et al233
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
139 patients with chronic subdural
hematomas. 51 managed with two
burr hole craniostomy, 3 with two burr holes and tissue plasminogen
activator, 73 with percutaneous
twist drill drainage, and 12 with
Good recovery: 111. Recurrence rate:
6 (two burr), 0 (two burr and tissue
plasminogen activator), 22 (percutaneous drainage), 0
(percutaneous drainage and tissue
plasminogen activator).
25
percutaneous twist drill drainage
and tissue plasminogen activator. 139 had drainage and 54 had
irrigation.
Secer et al234 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
32 patients with chronic subdural hematomas. Managed with burr
hole craaniostomy. 0 had drains and
32 had irrigation.
Recurrence rate: 5. Second recurrence: 0.
Stanisic et al235
(2012)
Prospective
observational study
Newcastle-Ottawa Scale:
High
56 patients with chronic subdural
hematomas. 18 used antiplatelets and 7 used anticoagulants. Managed
with one burr hole craniostomy for
24 hours and irrigation.
Mortality: 0. Morbidity: 0.
Recurrence rate: 3, managed with one burr hole.
Sundstrøm et
al236 (2012)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
60 patients with chronic subdural
hematomas. Managed with one burr
hole craniostomy.
Recurrence rate: 12.
Tahsim-Oglou
et al237 (2012)
Prospective
observational study
Newcastle-Ottawa Scale:
High
247 patients with 357 chronic
subdural hematomas. Managed with two burr hole craniostomy. 247 had
drains for 48 hours and irrigation.
Recurrence rate: 62, managed with
revision of surgery. Second recurrence: 13.
Takayama et al238 (2012)
Retrospective observational
study
Newcastle-Ottawa Scale: Low
239 patients with chronic subdural hematomas. Managed with burr
hole craniostomy. 239 had irrigation and drainage.
Recurrence rate: 21.
Wakabayashi et
al239 (2012)
Prospective
observational study
Newcastle-Ottawa Scale:
High
199 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 199 had drainage.
Recurrence rate: 14.
Yeon et al240 (2012)
Prospective observational
study
Newcastle-Ottawa Scale: High
20 patients with 22 chronic subdural hematomas. 24 used anticoagulants.
Managed with burr hole
craniostomy. 20 had drains for 24-48 hours. 0 had bed rest.
Mortality: 1. Morbidity: 1 (fever/infection), 1 (pulmonary
edema). Good recovery: 16.
Recurrence rate: 3, managed with burr hole. Second recurrence: 0
Baraniskin et
al241 (2013)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
163 patients with chronic subdural
hematomas. Managed with percutaneous twist drill drainage. 0
had drainage and irrigation.
Mortality: 13. Recurrence rate: 40.
Bosche et al242
(2012)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
18 patients with 24 chronic subdural
hematomas. 0 used anticoagulants.
Managed with burr hole craniostomy. 18 had closed system
drainage for 48-72 hours and
irrigation.
Recurrence rate: 6.
Ohba et al243
(2012)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
177 patients with chronic subdural
hematomas. Managed with one burr hole craniostomy. 177 had closed
system drainage for 24 hours, 13
had irrigation, and 177 had bed rest for 24 hours.
Recurrence rate: 20. Second
recurrence: 1.
Pahatouridis et
al244 (2012)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
245 patients with 286 chronic
subdural hematomas. 156 managed with two burr hole craniostomy and
89 with one burr hole. 245 had
drains for 48 hours and irrigation.
Recurrence rate: one burr hole: 5, two
burr holes: 9.
Safain et al245
(2013)
Prospective
observational study
Newcastle-Ottawa Scale:
High
46 patients with chronic subdural
hematomas. 23 managed with percutaneous twist drill drainage
and 23 with burr hole craniostomy
Mortality: percutaneous: 1,
traditional: 2/22. Cure rate: percutaneous: 20, traditional: 20.
Recurrence: percutaneous: 2,
26
or craniotomy (traditional). 23 had
drainage and irrigation.
traditional: 0, managed with burr
hole. Second recurrence: 0.
Singla et al246
(2012)
Retrospective
observational
study
Newcastle-Ottawa Scale:
High
52 patients with 61 chronic subdural
hematomas. 19 used antiplatelets
and 12 used anticoagulants. Managed with percutaneous twist
drill drainage. 52 had subdural
evacuating system drainage for 24-48 hours. 0 had bed rest.
Mortality: 1. Morbidity: 10
(pneumocephalus), 5 (seizure), 1
(acute epidural hematoma), 4 (acute subdural hematoma), 2 (pneumonia),
1 (multi-organ failure). Good
recovery: 38. Recurrence rate: 4, 3 managed with percutaneous drainage
and 1 with craniotomy.
Stanisic et al247
(2013)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
107 patients with 130 chronic
subdural hematomas. Managed with
one burr hole craniostomy. 107 had drainage and irrigation.
Mortality: 0. Recurrence rate: 7.
Tugcu et al248
(2013)
Retrospective
observational study
Newcastle-Ottawa Scale:
High
292 patients with 374 chronic
subdural hematomas. Managed with one burr hole craniostomy. 292 had
drainage and irrigation.
Mortality: 0. Recurrence rate: 43.
Yadav et al249
(2013)
Prospective
observational
study
Newcastle-Ottawa Scale:
High
50 patients with 58 chronic subdural
hematomas. Managed with
percutaneous twist drill drainage. 50 had drainage and 0 had irrigation.
Mortality: 0. Recurrence rate: 7,
managed with burr holes. Second
recurrence: 0.
Almenawer et al250 (2013)
Retrospective observational
study
Newcastle-Ottawa Scale: High
834 patients with chronic subdural hematomas. 219 managed with one
burr hole craniostomy, 204 with
two burr holes, 354 with percutaneous twist drill drainage,
and 57 with dexamethasone alone.
102 had adjuvant corticosteroids. 219 had drains. 204 had irrigation.
219 had bed rest.
Mortality: burr hole: 31 (16 one burr hole [with drainage], 15 two burr
holes [with irrigation]), percutaneous
drainage: 18 (6 adjuvant corticosteroid, 12 without adjuvant
corticosteroid), dexamethasone: 4.
Morbidity: burr hole: 64 (31 one burr hole [with drainage], 33 two burr hole
[with irrigation]), percutaneous
drainage: 45 (14 with adjuvant corticosteroid, 31 without adjuvant
corticosteroid), dexamethasone: 6.
Good recovery: burr hole: 360 (198 one burr hole [with drainage], 162
two burr holes [with irrigation]),
percutaneous drainage: 315 (91 with adjuvant corticosteroid, 254 without
adjuvant corticosteroid),
dexamethasone: 50. Recurrence rate: burr hole: 62 (30 one burr hole [with
drainage], 32 two burr holes [with
irrigation]), percutaneous drainage: 43 (14 with adjuvant corticosteroid,
29 without adjuvant corticosteroid),
dexamethasone: 6, managed with two burr holes. Second recurrence: 14.
Newcastle-Ottawa Scale quality assessment of observational studies results were based on the authors’ judgment about measuring comparability,
selection of cohorts, and assessment of outcomes. It was considered high if > 4 points and low if ≤ 4 points.
27
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34
Cochrane tool risk of bias assessment
35
Summary of the evidence (GRADE)1
Comparison Outcome Finding Quality of the evidence
(GRADE)
Percutaneous twist drill drainage
vs
Burr hole craniostomy
Craniotomy
vs
Percutaneous twist drill drainage
Corticosteroids
vs
Percutaneous twist drill drainage
Drains use
vs
No drainage
Irrigation
vs
No irrigation
Adjuvant corticosteroids use
vs
No steroids
One
vs
Two burr holes
Bed rest
vs
Activity as tolerated
Recurrence
Mortality
Mortality Cure rate
Recurrence Mortality
Morbidity
Cure rate
Recurrence
Mortality Morbidity
Cure rate
Recurrence
Mortality
Morbidity Cure rate
Recurrence Mortality
Morbidity Cure rate
Recurrence Mortality
Morbidity
Cure rate
Recurrence
Mortality Morbidity
Cure rate
Recurrence
Mortality
Morbidity Cure rate
No statistical difference
No statistical difference
No statistical difference No statistical difference
Favours craniotomy No statistical difference
Favours percutaneous drainage
No statistical difference
No statistical difference
No statistical difference No statistical difference
No statistical difference
Favours drains use
No statistical difference
No statistical difference No statistical difference
No statistical difference No statistical difference
No statistical difference No statistical difference
No statistical difference No statistical difference
Favours no steroids use
No statistical difference
No statistical difference
No statistical difference No statistical difference
No statistical difference
No statistical difference
No statistical difference
No statistical difference No statistical difference
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Very low ⊕⊝⊝⊝
Very low ⊕⊝⊝⊝
Very low ⊕⊝⊝⊝
Very low ⊕⊝⊝⊝
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
High ⊕⊕⊕⊕
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Moderate ⊕⊕⊕⊝
Moderate ⊕⊕⊕⊝
Moderate ⊕⊕⊕⊝
Moderate ⊕⊕⊕⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Moderate ⊕⊕⊕⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
Low ⊕⊕⊝⊝
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of
effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of
effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1Summary of the evidence as obtained from GRADE profiler 3.6 based on the authors’ judgment about the overall
evidence. Detailed Relative Risks (RRs), Confidence Intervals (CIs), heterogeneity (I2), pooled proportions, P
values, number of participants, and total number of included studies for variable outcomes were described in
different tables of the manuscript.