Drain Insertion in Chronic Subdural Hematoma: An International Survey of Practice

Abstract Objective The aim of this international survey was to investigate whether practice concerning drain insertion after burr hole drainage of cSDH following the publication of grade I evidence that it reduces recurrence rates has changed. Further, we aimed to document various practice modalities concerning the insertion of a drain adopted by neurosurgeons internationally. Methods We administered a survey to neurosurgeons all over the world with questions relating the surgical treatment of cSDH, emphasizing on their practices concerning the use of a drain. Results The preferred surgical technique was burr-hole drainage (89%). Most surgeons prefer to place a drain (80%), while in 56% of the cases the reason for not placing a drain was brain expansion after evacuation. Subdural drains are placed by 50% and subperiosteal drains by 27% of the responders, while 23% place primarily a subdural drain if possible and otherwise a subperiosteal drain. Three quarter of the responders leave the drain for 48 hours and give prophylactic antibiotic treatment, mostly a single-shot dose intraoperatively (70%). Routine postoperative CT is done by 59% mostly within 24-48 hours after surgery (94%). Adjunct treatment to surgery is rarely used (4%). Conclusion The publication of grade I evidence in favor of drain use influenced positively this practice worldwide. Some surgeons are still reluctant to insert a drain, especially when the subdural space is narrow after drainage of the hematoma. The insertion of a subperiosteal drain could be a good alternative solution. However, its outcome and efficacy must be evaluated in larger studies.