When the drain hits the brain
EANS Academy. Kamenova M. 09/27/19; 276044; EP05059
Dr. Maria Kamenova
Dr. Maria Kamenova

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Background: The insertion of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) was shown to reduce recurrence rate and improve outcome at 6 months. However, studies analyzing the rate of drain misplacement and complications associated with drain misplacement are sparse.
Methods: Retrospective analysis of consecutive patients undergoing burr-hole drainage for cSDH in two institutes. Drain type (subperiosteal (SPD) and SDD) inserted, drain misplacement rate, and drain-associated complications were analyzed. In addition, possible risk factors for drain misplacement and outcome after drain misplacement in patients where SDD was inserted were analyzed through univariate and multivariate analysis.
Results: Out of 463 included patients 62.6% received an SDD. Drain misplacement rate was 15.8%, of these 6.8% caused iatrogenic bleeding, and 12.3% caused neurological symptoms. Risk factors associated with drain misplacement in univariate analysis were acute on chronic hematomas, low preoperative GCS, no intraoperative brain expansion, advanced age, less midline shift (MLS) and smaller hematoma volume on preoperative computed tomography (CT), intake of vitamin K antagonists (VitKAnt) or different oral anticoagulants (DOACS), and longer discontinuation time of platelet inhibitors or anticoagulants. After multivariate analysis intake of VitKAnt (OR 3.64) or DOACS (OR 10.24), and low preoperative GCS (OR 7.81) remained associated risk factors for drain misplacement. Patients with misplaced drains showed a strong association with lower modified ranking scale (mRS) at release, higher rates of postoperative acute epidural or subdural hematomas, longer operation time, longer hospitalization time, and more frequent release to another hospital or rehabilitation facilities. After multivariate analysis postoperative bleedings (OR 5.81), longer operation time (OR 1.01), and hospitalization time (OR 1.08) remained strongly associated with drain misplacement.
Conclusion: The occurrence of SDD misplacement is unneglectable, since it leads to iatrogenic drain-associated complications, and affects outcome and hospitalization time of patients undergoing burr-hole drainage of cSDH.
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