The role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial

doi:10.1016/S0090-3019(02)00921-7

Surgical Neurology

Volume 58, Issue 6, December 2002, Pages 385-387

https://doi.org/10.1016/S0090-3019(02)00921-7 Get rights and content

Abstract

BACKGROUND

Chronic subdural hematoma is known to have a significant recurrence rate. In this report, we evaluate the relationship between the recurrence rate of chronic subdural hematoma and postoperative patient posture.

METHODS

We conducted a prospective randomized study of 46 patients with chronic subdural hematoma treated surgically at the Osaka City General Hospital from January 1997 to December 1999. In Group A, the patients were kept in a supine position for 3 days after the operation. In Group B, the patients assumed a sitting position on the day after the operation.

RESULTS

The recurrence rates in Group A and Group B were not significantly different.

CONCLUSIONS

Assuming an upright posture soon after operation in cases of chronic subdural hematoma is not thought to be a risk factor for recurrence.

Section snippets

Materials and methods

This is a prospective randomized study of 46 patients with chronic subdural hematoma treated surgically at the Osaka City General Hospital from January 1997 to December 1999. There were 32 males and 14 females and the mean age of the patients was 72.8 years (range 47–93 years).

In all patients, we performed single-burr hole irrigation of the hematoma cavity without closed system drainage. We evaluated the recurrence rate of chronic subdural hematoma based on two different postoperative patient

Results

Chronic subdural hematoma recurred in seven patients (15.2%). They were compared with non-recurrent cases in regard to age, sex, history of head trauma, chronic alcoholism, bilateral operations, and suspected bleeding tendency (patients on antiplatelets, anticoagulants, hemodialysis, or with liver cirrhosis). There were no statistically significant differences between them (Table 1).

In the prospective randomized study, the recurrence rate in Group A was 14.3% (4 of 24 cases) and that in Group

Discussion

Several groups of patients appear to be particularly vulnerable to postoperative recurrence. These include the elderly, chronic alcoholics, patients with bilateral operations, patients with a suspected bleeding tendency (those on anticoagulants, hemodialysis, or with coagulopathies), infants and children with subdural effusions and patients with cerebrospinal fluid shunts 2, 3, 4, 5, 6, 7, 9, 12, 13. Neither older patients, males, or those with a past history of head trauma, chronic alcoholism,

References (13)

N. Bruder et al.
Position du patient en neurochirurgie
Ann Fr Anesth Reanim
(1995)
W.F. Collins et al.
Peritoneal drainage of subdural hematomas in infants
J Pediatr
(1961)
W. McKissock
Subdural hematoma. A review of 389 cases
Lancet
(1960)
F. Porchet et al.
Effet de la position sur la pression intracranienne
Ann Fr Anesth Reanim
(1998)
D.M. Dooley et al.
Spontaneous intracranial hematomas in patient receiving anticoagulation therapy
JAMA
(1964)
R. Forelholm et al.
Chronic subdural hematoma in adults. Influence of patient’s age on symptoms, signs, and thickness of hematoma
J Neurosurg
(1975)

There are more references available in the full text version of this article.

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Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence.
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Subdural hematomaThe role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial

Abstract

Section snippets

Materials and methods

Results

Discussion

Ann Fr Anesth Reanim

J Pediatr

Lancet

Ann Fr Anesth Reanim

Spontaneous intracranial hematomas in patient receiving anticoagulation therapy

JAMA

Chronic subdural hematoma in adults. Influence of patient’s age on symptoms, signs, and thickness of hematoma

J Neurosurg

Subdural hematoma
The role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial