Comparative Clinical Outcomes of Irrigation Techniques in Burr-Hole Craniostomy for Chronic Subdural Hemorrhage: A Multicenter Cohort Study

Comparative Clinical Outcomes of Irrigation Techniques in Burr-Hole Craniostomy for Chronic Subdural Hemorrhage: A Multicenter Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Clinical Outcomes of Irrigation Techniques in Burr-Hole Craniostomy for Chronic Subdural Hemorrhage: A Multicenter Cohort Study Ho Seong Cho, Hyun-Seok Lee, Yoo Sung Jeon, Won Hee Lee, Kyung Rae Cho This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4279392/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jun, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background CSDH is often treated with surgical blood drainage, but concerns about recurrence and outcomes persist. Surgical techniques, including irrigation, vary. This study compares the outcomes of irrigation in cSDH surgery. Materials and methods From September 2020 to September 2022, 92 cSDH patients underwent surgery. Two different irrigation methods were used: extensive irrigation (IG) and non-irrigation (NIG). Method of irrigation was selected by each surgeon’s preference. Parameters measured included volume of hematoma changes, midline shifting, complications, and basic demographics. Recurrence was defined as symptomatic or hematoma expansion more than double the volume before surgery. Factors predicting recurrence and irrigation method impact were analyzed. Results Eleven patients were excluded because of bilateral or related to other disease. We analyzed 81 patients (44 NIG, 37 IG). Recurrence occurred in 6 IG cases (16.2%) and 1 NIG case (2.3%). Irrigation method significantly affected recurrence (P = 0.043). Age, gender, medication, medical history, and preoperative measurements had no major impact on recurrence. NIG had unexpected cases of intracerebral hemorrhage. Conclusion Extensive irrigation may increase recurrence in cSDH drainage. Non-irrigation drainage had fewer recurrences, but unexpected complications arose. Careful drainage in non-irrigated cases is crucial. chronic subdural hemorrhage burrhole Craniostomy irrigation recurrence Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chronic subdural hematoma (cSDH) represents a prevalent neurosurgical condition, amenable to treatment via hematoma drainage 5,23) . Primarily affecting elderly individuals, cSDH's annual incidence ranges from 1.72 to 20.60 per 100,000 persons, with associated morbidity and mortality ratios of 0–25% and 0–32%, respectively 5,25) . Despite the feasibility of addressing cSDH through a simple burr-hole procedure, recurrence rates reach up to 28%, and a considerable 20% of patients experience suboptimal neurological outcomes 25) . Surgical management of cSDH involves numerous contentious aspects, encompassing surgical technique, timing, burr hole count and placement, irrigation, drainage, optimal drainage positioning, drainage duration, membranectomy, and mid-meningeal artery embolization 24) . Within these debates, the role of irrigation remains equivocal, with some studies suggesting no discernible impact on outcomes 9,24) . This study endeavors to discern potential outcome disparities between two irrigation modalities, with patients randomly assigned to different procedure. Material and methods Between September 2020 and September 2022, a total of 92 patients underwent burr-hole craniostomy for chronic subdural hematoma (cSDH). Cases involving bilateral cSDH, acute or subacute subdural hematomas, or cSDH originating from hematologic malignancies or metastases were excluded, resulting in a final review of 81 cases. This study was approved by our institutional review board under the reference number KUMC 2022-10-063-002 Patient Allocation to Surgical Methods Patients with chronic subdural hematoma (cSDH) at a single institution were randomly assigned surgical procedures by the attending medical staff. Two groups of surgeons used distinct surgical methods. The Non-Irrigation Group (NIG) consisted of 44 cases, while the Irrigation Group (IG) encompassed 17 cases. Due to uneven numbers between two groups, 20 more cases from another institute that utilized the irrigation method were included in our study, which make total number of IG 37. Our primary endpoint was to compare the recurrence rate of cSDH between these two groups. Preoperative hematoma volume and midline shift width were measured. These measurements were repeated within a week post-surgery, and subsequently after a month, unless there were symptoms suggesting recurrence. Patient histories of prior cerebral infarction, hypertension, and diabetes mellitus were extracted from electronic medical records, as well as information on antiplatelet or anticoagulant medication usage. Surgical Procedures Upon creating a linear skin incision and burr hole using a high-speed drill, the dura was opened to expose the outer membrane of the cSDH. In the NIG, a subdural drain catheter was immediately inserted, gel-foam was applied to the burr hole site, and the skin was closed. Hematoma drainage was not performed during surgery in the NIG, relying instead on natural drainage through the drain tube without irrigation or aspiration. In the IG, after exposing the outer membrane of the cSDH upon dural opening, the hematoma was naturally drained and irrigated with saline until color dilution occurred. Closed irrigation through the drain tube was performed after skin closure. Postoperative CT scans of both methods were depicted in Fig. 1 . Hematoma Volume and Midline Shift Measurement, Definition of Recurrence The hematoma volume was calculated using a simplified methodology that involved multiplying and dividing the maximal width, length, and height measurements by 2. 20,25) The midline shift width was determined by measuring the displaced width of the third ventricle along an anterior-posterior falx line, midline. These measurements were conducted on CT taken preoperatively, immediately post-surgery, and one month later. Recurrence was defined as either an increase in hematoma volume exceeding twice the initial reduction or exacerbated symptoms necessitating revision surgery. Revision surgery was not undertaken if the patient displayed no change in symptoms, even in the presence of a significant hematoma recurrence. Patients who experienced an increase in hematoma volume without worsening of symptoms were closely monitored, and the majority of them showed hematoma absorption during follow-up. Statistical Analysis: In basic statistical analysis, normal continuous variables are summarized as Mean (SD) and assessed using a t-test for two groups. Non-normal continuous variables are summarized as median [IQR or min, max] and analyzed using the Kruskal-Wallis test. Categorical variables are presented in tabular format. To identify factors associated with recurrence, the Cox proportional hazard model was employed. Variables, including medication history, prior medical conditions, drainage duration, initial hematoma volume, midline shift width, and reduction rate, were analyzed to assess their impact on recurrence. All statistical analyses were conducted using R version 4.3, provided by the R Foundation, via the OpenStat.ai website, which is a service offered by Zarathu Co., Ltd. Result A total of 81 patients underwent 84 burr hole procedures, comprising 44 patients in the NIG and 37 in the IG. The mean ages were 69.4 and 73.6 for NIG and IG, respectively. Gender distribution showed 30 males (68.2%) and 14 females (31.8%) in NIG, and 20 males (54.1%) and 17 females (45.9%) in IG. Hypertension history was present in 19 NIG cases (43.2%) and 23 IG cases (62.2%), while 9 NIG cases (20.5%) and 11 NIG cases (29.7%) had a history of diabetes mellitus. Cerebral infarction history was noted in 12 NIG cases (27.3%) and 9 IG cases (24.3%). Additionally, 7 NIG cases (15.9%) and 11 IG cases (29.7%) were on antiplatelet agents. The median drain removal occurred 3.3 days in NIG and 2.5 days post-surgery in IG. When comparing the two different irrigation methods, there were no significant differences within each group, but it was notable that parietal burr hole placements were more frequently performed in IG (p = 0.002). The hematoma volume decreased from a mean of 121.9 cc to 39.8 cc in the NIG, resulting in a reduction rate of 65.2%. In the IG, the hematoma volume decreased from 137.6 cc to 46.0 cc, with a reduction rate of 65.4%, as measured immediately after surgery. The midline shift width decreased from 1.2 cm to 0.5 cm in NIG, reflecting a reduction rate of 58.0%, and from 1.1 cm to 0.6 cm in IG, with a reduction rate of 45.8%. The locations of burr-hole placements were as follows: in NIG, 35 (79.5%) in the frontal region, and nine (20.5%) in the parietal region. In IG, there were 17 (45.9%) in the frontal region, and 20 (54.1%) in the parietal region. There were more reduction of midline shift in NIG compared to IG (p = 0.024). But other factors didn’t show significant difference between two groups. Detailed demographics and results are presented in Table 1 . Table 1 Basic demographic features by two irrigation groups. Irrigation NIG IG p n 44 37 Sex (%) Male 30 (68.2) 20 (54.1) 0.283 Female 14 (31.8) 17 (45.9) Age 69.4 ± 10.9 73.6 ± 10.4 0.084 HTN (%) 0 25 (56.8) 14 (37.8) 0.139 1 19 (43.2) 23 (62.2) DM (%) 0 35 (79.5) 26 (70.3) 0.48 1 9 (20.5) 11 (29.7) Antiplatelet medication (%) 0 37 (84.1) 26 (70.3) 0.222 1 7 (15.9) 11 (29.7) Infarction (%) 0 32 (72.7) 28 (75.7) 0.962 1 12 (27.3) 9 (24.3) Location (%) F 35 (79.5) 17 (45.9) 0.002 P 9 (20.5) 20 (54.1) Pre_Volume 121.9 ± 42.8 137.6 ± 42.2 0.101 Immediate_Volume 39.8 ± 23.8 46.0 ± 25.6 0.266 Immediate reduction rate 65.2 ± 22.3 65.4 ± 20.2 0.958 Pre_Midline shift 1.2 ± 0.4 1.1 ± 0.4 0.488 Immediate_MS 0.5 ± 0.4 0.6 ± 0.2 0.39 MS reduction rate 58.0 ± 25.3 45.8 ± 22.4 0.024 Drain duration 3.3 ± 2.1 2.5 ± 1.8 0.06 Recurr (%) 0 43 (97.7) 31 (83.8) 0.043 1 1 ( 2.3) 6 (16.2) time_to_recur 458.5 ± 229.3 478.8 ± 256.6 0.711 The location of the burr hole and the reduction rate of midline shift differed between the two groups. However, patient demographics were largely similar. HTN: hypertension; DM: Diabetes Mellitus; F: Frontal; P: Parietal; MS: Midline shift Out of the 81 cases, seven recurrences were observed on follow-up CT scans, necessitating second surgeries to evacuate residual hematoma Recurrence occurred in one (2.3%) patient in NIG, but six (16.2%) recurrences were found in IG, and this difference was statistically significant ( p = 0.043 ). Considering time to recurrence, we compared and analyzed recurrence rate between two different methods. In statistical analysis, only difference in irrigation method showed a significant correlation with an increased recurrence rate ( p = 0.01 ). Reduction rate of midline shift and burr hole location, which showed significant difference did not related to the recurrence. This result was shown in Table 2 . Additionally, the Kaplan-Meier plot illustrating recurrence by irrigation method is depicted in Fig. 2 . Table 2 Cox proportional hazard model predicting recurrence by time crude HR(95%CI) crude P value adj. HR(95%CI) adj. P value Sex: F vs M 0.63 (0.12,3.24) 0.58 0.67 (0.07,6.1) 0.724 Age 1 (0.93,1.07) 0.956 0.94 (0.81,1.09) 0.422 HTN 1.22 (0.27,5.47) 0.791 0.24 (0.02,2.4) 0.227 DM 1.2 (0.23,6.2) 0.825 1.34 (0.12,14.6) 0.811 Medication 2.72 (0.61,12.15) 0.191 4.98 (0.51,48.58) 0.167 Infarction 1.17 (0.23,6.03) 0.852 0.33 (0.03,4.19) 0.39 Irrigation 8.09 (1.0,65.2) 0.049 15.24 (7.26,32.02) 0.01 Location(ref:F) P 2.26 (0.51,10.11) 0.285 1.63 (0.19,13.9) 0.655 Pre_Volume 1 (0.98,1.02) 0.857 1 (0.94,1.06) 0.945 Immediate_Volume 1.02 (0.99,1.05) 0.268 1.04 (0.91,1.18) 0.595 Immediate reduction rate 1.01 (0.98,1.05) 0.408 1.04 (0.89,1.2) 0.639 Pre_Midline shift 0.93 (0.16,5.45) 0.936 43.69 (0.07,25803.83) 0.246 Immediate_MS 0.62 (0.05,8.38) 0.718 0 (0,209.61) 0.228 MS reduction rate 1 (0.97,1.03) 0.9 1.03 (0.92,1.16) 0.579 Drain duration 0.8 (0.48,1.32) 0.38 0.83 (0.45,1.53) 0.555 HTN: hypertension; DM: Diabetes Mellitus; F: Frontal; P: Parietal; MS: Midline shift According to our definition of recurrence, any cases that showed hematoma expansion exceeding double the volume measured immediately post-surgery were classified as recurrences. However, when examining the cases that required re-surgery, it was observed that one case in NIG group and two cases in IG group required revision surgery. Furthermore, there were no identifiable predictive factors or differences between the two groups in these re-surgical cases. In addition to recurrences, unexpected complications occurred in NIG, with two cases experiencing unforeseen ipsilateral intracranial hemorrhage post-surgery. Both patients in NIG exhibited ipsilateral intracranial hemorrhage on the first postoperative day. No other complications were observed in the IG. Detailed descriptions of these complicated cases are provided separately. Complicated cases Case 1 A seventy-three-year-old man came to the emergency department with left-sided weakness and a drowsy mental status. He had a history of hypertension and was taking hypertension medication along with aspirin (100mg daily). The preoperative CT (Fig. 3 A) showed approximately 154.5cc of hematoma, causing midline shift of about 2.07cm and uncal herniation. A frontal burr hole with a catheter was inserted directly without the irrigation of hematoma. A CT scan taken immediately after the surgery showed minimal high density at the right frontal lobe, but the patient had no specific neurological changes. (Fig. 3 B) A day after the surgery, following the drainage of 200cc of hematoma, a brain CT scan was performed, which showed an reduced amount of cSDH to 19.4cc but increase of about 10cc of intracerebral hemorrhage (ICH). (Fig. 3 C) Fortunately, there were no specific neurological deficits aggravated, and the hemorrhage remained stable. The patient's mental status and left-sided weakness improved, and he was discharged 20 days after the surgery. Case 2 A ninety-six-year-old woman came to the clinic with left-sided weakness that had been persisting for a week. Her medical history revealed two head trauma events about 2 weeks prior. She had a history of hypertension, diabetes mellitus, dyslipidemia, asthma, and Alzheimer's disease. She was taking multiple medications; however, there were no antiplatelet or anticoagulants prescribed before. Her preoperative CT showed a chronic subdural hemorrhage on the right side, along with a small amount of subdural hemorrhage in the left frontal area (see Fig. 4 A). After recovering from anesthesia, she exhibited confusion, but her weakness had slightly improved compared to the preoperative state. The postoperative CT showed a well-placed catheter without immediate complications (Fig. 4 B). However, a day after surgery, her left-sided weakness worsened to grade 1. An emergent CT was performed and revealed a massive intracerebral hemorrhage (ICH) in the ipsilateral frontal lobe (Fig. 4 C). Her mental state had slightly improved, but her weakness did not improve, and she was discharged without significant improvement. Discussion Chronic subdural hematoma (cSDH) represents a prevalent concern in the field of neurosurgery, particularly among elderly individuals. Burr-hole craniostomy is the established treatment modality for cSDH. Controversies encompass various dimensions, including factors such as sex, age, medical history, the number and locations of burr holes, as well as the utilization of irrigation in management 19) . This investigation specifically delves into the divergence between irrigation and non-irrigation approaches in the treatment of cSDH. The difference between our irrigated and non-irrigated procedures was primarily determined by the surgeon, with other variables such as subacute hematoma components, antiplatelet usage, and comorbidities remaining relatively consistent. Several factors contribute to the increased incidence of chronic subdural hematoma (cSDH), including advanced age, male gender, and concurrent medical conditions such as hemodialysis or anticoagulant/antiplatelet therapies. However, conclusive evidence substantiating their role in recurrence rates remains lacking. Notably, our study excludes cases of bilateral cSDH, as Ishita et al. highlighted a correlation between bilateral cSDH and an increased recurrence risk 14) . Krupp et al. underscored the importance of patient age and admission condition in the context of chronic subdural hematoma (cSDH) recurrence, suggesting that advanced age and compromised neurological status increase the likelihood of recurrence 10,17) . However, in our study, there was no significant difference in recurrence rates with increasing age. Frantz et al. conducted a prospective randomized controlled trial to assess the impact of ACE inhibitors, specifically perindopril, on recurrence, but no significant effect was observed 16) . In contrast, Neidert et al.'s retrospective case-control study revealed elevated hematoma volumes and increased recurrence frequency in patients treated with ACE inhibitors as an adjunct to surgery 15) . Unfortunately, our study did not analyze the use of ACE inhibitors, but we did analyze patients with hypertension and found no association with an increased risk of recurrence or preventive effect. There are ongoing debates regarding the use of antiplatelet medications in relation to cSDH recurrence. Several previous studies have demonstrated no relationship between the use of drugs affecting hemostasis and recurrence 3,4,8) . Similarly, we found no significant difference in recurrence with or without antiplatelet use. Preoperative midline shift ≥ 10 mm, severe brain atrophy, post-operative severe pneumocephalus, and hematoma drainage volume ≥ 100 mL are independent radiographic risk factors for CSDH recurrence 1,18) . For these factors, we couldn't find the same results as in previous reports, but we can estimate that immediate reduction of midline shift could possibly affect the recurrence rate. Moreover, there are many reports suggesting that post-op pneumocephalus and its volume are reliable factors for recurrence 12) The role of irrigation remains unclear. Some studies have shown no significant differences in the recurrence rates with or without irrigation 13,21) Numerous investigations indicate comparable efficacy of irrigation and non-irrigation procedures for treating chronic SDH in terms of recurrence outcomes argued that the outcome with or without irrigation is the same in cSDH managed by a drainage system. 7,24,26,27) . Suzuki and associates reported a recurrence rate of 3.4% for the group without irrigation, and 3% for the group with irrigation. The difference did not reach significance. 21) In the series by Matsumoto et al eight of 121 patients had no intraoperative irrigation. There were no significant differences in the recurrence rates. 13) In Kuroki’s series, the recurrence rate was 3.6% without irrigation and 13.3% with irrigation. 11) Our study corroborates this trend, demonstrating recurrence rates of 16.2% in the Irrigation Group (IG) and 2.3% in the Non-Irrigation Group (NIG). While subdural hematoma irrigation along with the modulation of chemokines within the hematoma may seemingly offer a potential means to reduce recurrence rates, a substantial body of literature suggests that extensive irrigation can engender pneumocephalus within the subdural space 6,22) . This phenomenon can impede brain expansion, subsequently contributing to recurrent subdural hematoma formation. For summarizing evidences, we could hypothesize that irrigation of SDH while surgery can make pneumocephalus that can impede brain expansion. And those delayed brain expansion can make residual hematoma can format another chronic hematoma and recur. Evidently, non-irrigation emerges as a more effective treatment avenue than irrigation for reducing recurrence rates in cSDH in our study. Furthermore, we couldn’t find significance in recurrence prediction of midline shift reduction, however, reduction rate of midline shift was significantly higher in NIG and that can may because of post operative pneumocephalus due to massive irrigation which seems to impede brain expansion after surgery. While potential biases may be present, unforeseen complications were observed in the NIG. Overdrainage of cSDH may lead to microbleeding due to rapid pressure gradient changes, thereby increasing the risk of ICH 2) . Since the NIG cannot carefully insert a drainage catheter while observing the brain's surface, there is a possibi 4) lity of serious complications, such as catheter penetration of the cerebral cortex, leading to ICH and related issues. While we are not certain why these serious complications occurred, it's worth noting that both patients were taking antiplatelet agents, specifically cilostazol and 3) clopidogrel, which may increase their risk of hemorrhage compared to others. Consequently, we advise surgeons to exercise caution when considering rapid drainage in cases of non-irrigated hematoma in order to mitigate the risk of ICH. Limitations Patients were randomly assigned to surgeons who utilized distinct surgical techniques. However, the uneven distribution of patients between the Irrigation Group (IG) and the Non-Irrigation Group (NIG) (44 vs. 37), coupled with the low recurrence rates, could potentially undermine the robustness of the findings. Categorizing the surgical methods into two broad groups, hematoma irrigation or non-irrigation, may obscure potential nuances stemming from variations in individual surgical practices, which could also impact surgical outcomes. Despite these limitations, our study highlights significant differences between the two groups. However, given the small recurrence rate in relation to the total number of surgeries, and the fact that only one case in each group required revision surgery, statistical analysis couldn't be performed with precision. Therefore, further studies with larger cohorts are necessary to obtain more conclusive results. Conclusion In our investigation, extensive irrigation for cSDH exhibited a potential association with heightened recurrence rates compared to the non-irrigation approach of simple drainage. Furthermore, aside from the recurrence aspect, unexpected and severe intracerebral hemorrhagic complications emerged within the NIG. Although a causal link remains speculative, the occurrence warrants further scrutiny. The complexity of these findings underscores the necessity for rigorous high-quality randomized controlled trials to delve into this matter more comprehensively. During the preparation of this work the authors used ChatGPT, an AI language model developed by OpenAI in order to enhance the article's readability by ensuring grammatical correctness and providing readers with the intended information. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Declarations Author Contribution HSC : Conceptualization; Data curation; Formal analysis; Writing original draftHSL : Data curation; Statistical analysisYSJ : Data curation; Editing original draftWHL : Data curation; Editing original draft; Supervision; ValidationKRC : Conceptualization; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Data curation; Formal analysis; Writing and editing original draft; References Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, et al. : Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg 259 : 449-457, 2014 An SJ, Kim TJ, Yoon BW : Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke 19 : 3-10, 2017 Choi J, Pyen J, Cho S, Kim J, Koo Y, Whang K : Influence of Antithrombotic Medication on the Risk of Chronic Subdural Hematoma Recurrence after Burr-Hole Surgery. J Korean Neurosurg Soc 63 : 513-518, 2020 De Bonis P, Trevisi G, de Waure C, Sferrazza A, Volpe M, Pompucci A, et al. : Antiplatelet/anticoagulant agents and chronic subdural hematoma in the elderly. PLoS One 8 : e68732, 2013 Feghali J, Yang W, Huang J : Updates in Chronic Subdural Hematoma: Epidemiology, Etiology, Pathogenesis, Treatment, and Outcome. World Neurosurg 141 : 339-345, 2020 Guo X, Wu L, Ou Y, Yu X, Zhu B, Yang C, Liu W : Postoperative pneumocephalus and recurrence and outcome of chronic subdural hematoma: a systematic review and meta-analysis. Neurosurg Rev 46 : 13, 2022 Iftikhar M, Siddiqui UT, Rauf MY, Malik AO, Javed G : Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma. J Neurol Surg A Cent Eur Neurosurg 77 : 416-421, 2016 Kamenova M, Lutz K, Schaedelin S, Fandino J, Mariani L, Soleman J : Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates? Neurosurgery 79 : 715-721, 2016 Kolias AG, Chari A, Santarius T, Hutchinson PJ : Chronic subdural haematoma: modern management and emerging therapies. Nat Rev Neurol 10 : 570-578, 2014 Krupp WF, Jans PJ : Treatment of chronic subdural haematoma with burr-hole craniostomy and closed drainage. Br J Neurosurg 9 : 619-627, 1995 Kuroki T, Katsume M, Harada N, Yamazaki T, Aoki K, Takasu N : Strict closed-system drainage for treating chronic subdural haematoma. Acta Neurochir (Wien) 143 : 1041-1044, 2001 Liu W, Bakker NA, Groen RJ : Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 121 : 665-673, 2014 Matsumoto K, Akagi K, Abekura M, Ryujin H, Ohkawa M, Iwasa N, Akiyama C : Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage. Neurol Res 21 : 277-280, 1999 Miah IP, Tank Y, Rosendaal FR, Peul WC, Dammers R, Lingsma HF, et al. : Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology 63 : 27-40, 2021 Neidert MC, Schmidt T, Mitova T, Fierstra J, Bellut D, Regli L, et al. : Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: Associations with initial presentation and clinical outcome. J Clin Neurosci 28 : 82-86, 2016 Poulsen FR, Munthe S, Soe M, Halle B : Perindopril and residual chronic subdural hematoma volumes six weeks after burr hole surgery: a randomized trial. Clin Neurol Neurosurg 123 : 4-8, 2014 Rauhala M, Luoto TM, Huhtala H, Iverson GL, Niskakangas T, Ohman J, Helen P : The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population. J Neurosurg 132 : 1147-1157, 2019 Shen J, Yuan L, Ge R, Wang Q, Zhou W, Jiang XC, Shao X : Clinical and radiological factors predicting recurrence of chronic subdural hematoma: A retrospective cohort study. Injury 50 : 1634-1640, 2019 Solou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, et al. : Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics (Basel) 12 , 2022 Sucu HK, Gokmen M, Gelal F : The value of XYZ/2 technique compared with computer-assisted volumetric analysis to estimate the volume of chronic subdural hematoma. Stroke 36 : 998-1000, 2005 Suzuki K, Sugita K, Akai T, Takahata T, Sonobe M, Takahashi S : Treatment of chronic subdural hematoma by closed-system drainage without irrigation. Surg Neurol 50 : 231-234, 1998 Suzuki M, Endo S, Inada K, Kudo A, Kitakami A, Kuroda K, Ogawa A : Inflammatory cytokines locally elevated in chronic subdural haematoma. Acta Neurochir (Wien) 140 : 51-55, 1998 Tamura R, Sato M, Yoshida K, Toda M : History and current progress of chronic subdural hematoma. J Neurol Sci 429 : 118066, 2021 Weigel R, Schmiedek P, Krauss JK : Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74 : 937-943, 2003 Won SY, Zagorcic A, Dubinski D, Quick-Weller J, Herrmann E, Seifert V, Konczalla J : Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. PLoS One 13 : e0199809, 2018 Xu C, Chen S, Yuan L, Jing Y : Burr-hole Irrigation with Closed-system Drainage for the Treatment of Chronic Subdural Hematoma: A Meta-analysis. Neurol Med Chir (Tokyo) 56 : 62-68, 2016 Yuan Y, Wang QP, Cao YL, Zhang H, Burkutally MSN, Budryte K, Xiong N : Burr hole drainage and burr hole drainage with irrigation to treat chronic subdural hematoma: A systematic review and meta-analysis. Medicine (Baltimore) 97 : e11827, 2018 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jun, 2024 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 08 May, 2024 Reviews received at journal 03 May, 2024 Reviews received at journal 01 May, 2024 Reviewers agreed at journal 21 Apr, 2024 Reviewers agreed at journal 20 Apr, 2024 Reviewers invited by journal 20 Apr, 2024 Editor assigned by journal 20 Apr, 2024 Submission checks completed at journal 18 Apr, 2024 First submitted to journal 17 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4279392","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293749681,"identity":"8acc8a8a-4764-46c0-99da-d5ca438e98cb","order_by":0,"name":"Ho Seong Cho","email":"","orcid":"","institution":"Konkuk University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ho","middleName":"Seong","lastName":"Cho","suffix":""},{"id":293749682,"identity":"174ca436-0d05-4bfa-bb74-2bf4db39486c","order_by":1,"name":"Hyun-Seok Lee","email":"","orcid":"","institution":"Konkuk University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Hyun-Seok","middleName":"","lastName":"Lee","suffix":""},{"id":293749683,"identity":"cdf9d8c0-ef65-40b7-8b82-ea34abfd1043","order_by":2,"name":"Yoo Sung Jeon","email":"","orcid":"","institution":"Konkuk University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Yoo","middleName":"Sung","lastName":"Jeon","suffix":""},{"id":293749684,"identity":"71aa0858-826c-4ce8-bce0-aed37f2a7954","order_by":3,"name":"Won Hee Lee","email":"","orcid":"","institution":"Inje University Busan Paik Hospital","correspondingAuthor":false,"prefix":"","firstName":"Won","middleName":"Hee","lastName":"Lee","suffix":""},{"id":293749685,"identity":"33b93a5c-8417-4d76-968f-951be8e01cbf","order_by":4,"name":"Kyung Rae Cho","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYHACgwNQBuMDIMHDR6wWCSBmNgBpYSNGCwNUCxuIYCCoRbe9eeOBHzV1dfzSx59Vfs2xk2FjYH746AYeLWZnjhUc7Dl2WEKyLyHttuy2ZKDD2IyNc/BpuZFjcJiB7YCEwRmGY7cltzEDtfCwSePVcv8NUMu/Ogn7M4xtxZLb6onQcoPH4DBjG7OEAQ8zG+PHbYeJ0HImreBgb99hyRln2JilGbcd52FjJuSX44c3f/jxrY6fv4f94cef26rt+dmbHz7GpwUFMPOASWKVgwDjD1JUj4JRMApGwYgBAMF8RgEcjRLbAAAAAElFTkSuQmCC","orcid":"","institution":"Konkuk University Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Kyung","middleName":"Rae","lastName":"Cho","suffix":""}],"badges":[],"createdAt":"2024-04-17 05:12:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4279392/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4279392/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-024-02586-9","type":"published","date":"2024-07-01T00:35:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55523432,"identity":"0fec7ae8-e301-414d-bc71-cdb39a48e64e","added_by":"auto","created_at":"2024-04-29 14:31:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92444,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Preoperative and Immediate Postoperative CT Scans between the Irrigation(IG) and Non-Irrigation(NIG) Methods. Panels A and B show the CT images before surgery (preoperative) and immediately after surgery (immediate postoperative) for the IG, while panels C and D display the pre- and postoperative CT scans for the NIG.\u003c/p\u003e","description":"","filename":"SDHFig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4279392/v1/dc97bde9880045eca9dc2302.jpg"},{"id":55523428,"identity":"90bcfaad-d9fd-423b-86b1-974a6b580d2c","added_by":"auto","created_at":"2024-04-29 14:31:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37348,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan meier plot for recurrence by time to recur in both irrigation group. Irrigation group showed significant higher rate of recurrence in log-rank test. (p=0.029)\u003c/p\u003e","description":"","filename":"SDHFig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4279392/v1/906937d0a95d334c839b3dd1.jpg"},{"id":55524747,"identity":"366b14b8-c4f1-4253-be82-405eb3b2b873","added_by":"auto","created_at":"2024-04-29 14:39:07","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":108821,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan of intracranial hemorrhage in a post-surgery case:\u003c/p\u003e\n\u003cp\u003eA: The preoperative CT scan reveals the presence of approximately 154.5cc of chronic subdural hematoma, causing contralateral brain displacement of 2.1cm.\u003c/p\u003e\n\u003cp\u003eB: After performing a burr hole craniostomy and catheter insertion, there is a noticeable reduction in the hematoma volume to 19.4cc. Additionally, slight high-density areas are observed in the ipsilateral frontal region, suggestive of intracerebral hemorrhage (ICH, white arrow.).\u003c/p\u003e\n\u003cp\u003eC: One day after the surgical procedure, the subdural hematoma has further diminished in size, while the volume of ICH has increased. Fortunately, the patient remained stable without experiencing any neurological deficits.\u003c/p\u003e","description":"","filename":"SDHFig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4279392/v1/e729aba95f96acd6d2d13dc8.jpg"},{"id":55523430,"identity":"d93de44e-0a5f-477b-8c8c-b901e53b0226","added_by":"auto","created_at":"2024-04-29 14:31:07","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":118263,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan of the second case of intracranial hemorrhage in a post-surgery scenario:\u003c/p\u003e\n\u003cp\u003eA: The preoperative CT scan reveals the presence of approximately 110cc of chronic subdural hematoma, primarily on the left side, with a small amount of subdural hematoma also noted in the left frontal region.\u003c/p\u003e\n\u003cp\u003eB: Following the burr hole craniostomy and catheter insertion, there was a reduction in the subdural hematoma to 23.6cc, accompanied by an improvement in her symptoms. However, her postoperative confusion persisted.\u003c/p\u003e\n\u003cp\u003eC: One day after the surgery, her left-sided motor function deteriorated from grade 4 to grade 1 in both the upper and lower limbs. A CT scan showed the presence of a massive intracerebral hemorrhage (ICH) in her left frontal lobe.\u003c/p\u003e","description":"","filename":"SDHFig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4279392/v1/d00aa4b7ea7164ba1b0c894c.jpg"},{"id":59447057,"identity":"7205a495-48ac-40fb-926d-18ac2755b773","added_by":"auto","created_at":"2024-07-02 00:35:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":997554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4279392/v1/d701a1a7-8b1c-4fb0-aa61-23550eb93ef3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Clinical Outcomes of Irrigation Techniques in Burr-Hole Craniostomy for Chronic Subdural Hemorrhage: A Multicenter Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic subdural hematoma (cSDH) represents a prevalent neurosurgical condition, amenable to treatment via hematoma drainage\u003csup\u003e5,23)\u003c/sup\u003e. Primarily affecting elderly individuals, cSDH's annual incidence ranges from 1.72 to 20.60 per 100,000 persons, with associated morbidity and mortality ratios of 0\u0026ndash;25% and 0\u0026ndash;32%, respectively\u003csup\u003e5,25)\u003c/sup\u003e. Despite the feasibility of addressing cSDH through a simple burr-hole procedure, recurrence rates reach up to 28%, and a considerable 20% of patients experience suboptimal neurological outcomes \u003csup\u003e25)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSurgical management of cSDH involves numerous contentious aspects, encompassing surgical technique, timing, burr hole count and placement, irrigation, drainage, optimal drainage positioning, drainage duration, membranectomy, and mid-meningeal artery embolization\u003csup\u003e24)\u003c/sup\u003e. Within these debates, the role of irrigation remains equivocal, with some studies suggesting no discernible impact on outcomes \u003csup\u003e9,24)\u003c/sup\u003e. This study endeavors to discern potential outcome disparities between two irrigation modalities, with patients randomly assigned to different procedure.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eBetween September 2020 and September 2022, a total of 92 patients underwent burr-hole craniostomy for chronic subdural hematoma (cSDH). Cases involving bilateral cSDH, acute or subacute subdural hematomas, or cSDH originating from hematologic malignancies or metastases were excluded, resulting in a final review of 81 cases. This study was approved by our institutional review board under the reference number KUMC 2022-10-063-002\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Allocation to Surgical Methods\u003c/h2\u003e \u003cp\u003ePatients with chronic subdural hematoma (cSDH) at a single institution were randomly assigned surgical procedures by the attending medical staff. Two groups of surgeons used distinct surgical methods. The Non-Irrigation Group (NIG) consisted of 44 cases, while the Irrigation Group (IG) encompassed 17 cases. Due to uneven numbers between two groups, 20 more cases from another institute that utilized the irrigation method were included in our study, which make total number of IG 37. Our primary endpoint was to compare the recurrence rate of cSDH between these two groups. Preoperative hematoma volume and midline shift width were measured. These measurements were repeated within a week post-surgery, and subsequently after a month, unless there were symptoms suggesting recurrence. Patient histories of prior cerebral infarction, hypertension, and diabetes mellitus were extracted from electronic medical records, as well as information on antiplatelet or anticoagulant medication usage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedures\u003c/h2\u003e \u003cp\u003eUpon creating a linear skin incision and burr hole using a high-speed drill, the dura was opened to expose the outer membrane of the cSDH. In the NIG, a subdural drain catheter was immediately inserted, gel-foam was applied to the burr hole site, and the skin was closed. Hematoma drainage was not performed during surgery in the NIG, relying instead on natural drainage through the drain tube without irrigation or aspiration. In the IG, after exposing the outer membrane of the cSDH upon dural opening, the hematoma was naturally drained and irrigated with saline until color dilution occurred. Closed irrigation through the drain tube was performed after skin closure. Postoperative CT scans of both methods were depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eHematoma Volume and Midline Shift Measurement, Definition of Recurrence\u003c/h2\u003e \u003cp\u003eThe hematoma volume was calculated using a simplified methodology that involved multiplying and dividing the maximal width, length, and height measurements by 2.\u003csup\u003e20,25)\u003c/sup\u003e The midline shift width was determined by measuring the displaced width of the third ventricle along an anterior-posterior falx line, midline. These measurements were conducted on CT taken preoperatively, immediately post-surgery, and one month later. Recurrence was defined as either an increase in hematoma volume exceeding twice the initial reduction or exacerbated symptoms necessitating revision surgery. Revision surgery was not undertaken if the patient displayed no change in symptoms, even in the presence of a significant hematoma recurrence. Patients who experienced an increase in hematoma volume without worsening of symptoms were closely monitored, and the majority of them showed hematoma absorption during follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eIn basic statistical analysis, normal continuous variables are summarized as Mean (SD) and assessed using a t-test for two groups. Non-normal continuous variables are summarized as median [IQR or min, max] and analyzed using the Kruskal-Wallis test. Categorical variables are presented in tabular format.\u003c/p\u003e \u003cp\u003eTo identify factors associated with recurrence, the Cox proportional hazard model was employed. Variables, including medication history, prior medical conditions, drainage duration, initial hematoma volume, midline shift width, and reduction rate, were analyzed to assess their impact on recurrence.\u003c/p\u003e \u003cp\u003eAll statistical analyses were conducted using R version 4.3, provided by the R Foundation, via the OpenStat.ai website, which is a service offered by Zarathu Co., Ltd.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 81 patients underwent 84 burr hole procedures, comprising 44 patients in the NIG and 37 in the IG. The mean ages were 69.4 and 73.6 for NIG and IG, respectively. Gender distribution showed 30 males (68.2%) and 14 females (31.8%) in NIG, and 20 males (54.1%) and 17 females (45.9%) in IG. Hypertension history was present in 19 NIG cases (43.2%) and 23 IG cases (62.2%), while 9 NIG cases (20.5%) and 11 NIG cases (29.7%) had a history of diabetes mellitus. Cerebral infarction history was noted in 12 NIG cases (27.3%) and 9 IG cases (24.3%). Additionally, 7 NIG cases (15.9%) and 11 IG cases (29.7%) were on antiplatelet agents. The median drain removal occurred 3.3 days in NIG and 2.5 days post-surgery in IG. When comparing the two different irrigation methods, there were no significant differences within each group, but it was notable that parietal burr hole placements were more frequently performed in IG (p = 0.002).\u003c/p\u003e\u003cp\u003eThe hematoma volume decreased from a mean of 121.9 cc to 39.8 cc in the NIG, resulting in a reduction rate of 65.2%. In the IG, the hematoma volume decreased from 137.6 cc to 46.0 cc, with a reduction rate of 65.4%, as measured immediately after surgery. The midline shift width decreased from 1.2 cm to 0.5 cm in NIG, reflecting a reduction rate of 58.0%, and from 1.1 cm to 0.6 cm in IG, with a reduction rate of 45.8%. The locations of burr-hole placements were as follows: in NIG, 35 (79.5%) in the frontal region, and nine (20.5%) in the parietal region. In IG, there were 17 (45.9%) in the frontal region, and 20 (54.1%) in the parietal region. There were more reduction of midline shift in NIG compared to IG (p = 0.024). But other factors didn’t show significant difference between two groups. Detailed demographics and results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic demographic features by two irrigation groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIrrigation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNIG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eIG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (68.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (54.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (31.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.4 ± 10.9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.6 ± 10.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (56.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.139\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (43.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (62.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (79.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (70.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (29.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAntiplatelet\u003c/p\u003e \u003cp\u003emedication (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (84.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (70.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (15.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (29.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfarction (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (72.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (75.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.962\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (27.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (24.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (79.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (54.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_Volume\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121.9 ± 42.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e137.6 ± 42.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediate_Volume\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.8 ± 23.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.0 ± 25.6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.266\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eImmediate reduction rate\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.2 ± 22.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.4 ± 20.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre_Midline shift\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2 ± 0.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1 ± 0.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediate_MS\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5 ± 0.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6 ± 0.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMS reduction rate\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.0 ± 25.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.8 ± 22.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrain duration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3 ± 2.1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5 ± 1.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurr (%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (97.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (83.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 ( 2.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (16.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etime_to_recur\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e458.5 ± 229.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e478.8 ± 256.6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eThe location of the burr hole and the reduction rate of midline shift differed between the two groups. However, patient demographics were largely similar.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eHTN: hypertension; DM: Diabetes Mellitus; F: Frontal; P: Parietal; MS: Midline shift\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eOut of the 81 cases, seven recurrences were observed on follow-up CT scans, necessitating second surgeries to evacuate residual hematoma Recurrence occurred in one (2.3%) patient in NIG, but six (16.2%) recurrences were found in IG, and this difference was statistically significant (\u003cem\u003ep = 0.043\u003c/em\u003e).\u003c/p\u003e\u003cp\u003eConsidering time to recurrence, we compared and analyzed recurrence rate between two different methods. In statistical analysis, only difference in irrigation method showed a significant correlation with an increased recurrence rate (\u003cem\u003ep = 0.01\u003c/em\u003e). Reduction rate of midline shift and burr hole location, which showed significant difference did not related to the recurrence. This result was shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Additionally, the Kaplan-Meier plot illustrating recurrence by irrigation method is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCox proportional hazard model predicting recurrence by time\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 15.9418%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003ecrude HR(95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003ecrude P value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003eadj. HR(95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 6.0225%;\"\u003e\n \u003cp\u003eadj. P value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eSex: F vs M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e0.63 (0.12,3.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0.67 (0.07,6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1 (0.93,1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0.94 (0.81,1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1.22 (0.27,5.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0.24 (0.02,2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1.2 (0.23,6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1.34 (0.12,14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.811\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e2.72 (0.61,12.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e4.98 (0.51,48.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eInfarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1.17 (0.23,6.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0.33 (0.03,4.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eIrrigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e8.09 (1.0,65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 17.1817%;\"\u003e\n \u003cp\u003e15.24 (7.26,32.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 5.7568%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eLocation(ref:F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e2.26 (0.51,10.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1.63 (0.19,13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003ePre_Volume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1 (0.98,1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.857\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1 (0.94,1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eImmediate_Volume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1.02 (0.99,1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1.04 (0.91,1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eImmediate reduction rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1.01 (0.98,1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1.04 (0.89,1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003ePre_Midline shift\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e0.93 (0.16,5.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e43.69 (0.07,25803.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eImmediate_MS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e0.62 (0.05,8.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.718\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0 (0,209.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.228\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eMS reduction rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e1 (0.97,1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e1.03 (0.92,1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 15.9418%;\"\u003e\n \u003cp\u003eDrain duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.6649%;\"\u003e\n \u003cp\u003e0.8 (0.48,1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.2994%;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.1705%;\"\u003e\n \u003cp\u003e0.83 (0.45,1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 8.768%;\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 60.8446%;\"\u003eHTN: hypertension; DM: Diabetes Mellitus; F: Frontal; P: Parietal; MS: Midline shift\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\u003cp\u003eAccording to our definition of recurrence, any cases that showed hematoma expansion exceeding double the volume measured immediately post-surgery were classified as recurrences. However, when examining the cases that required re-surgery, it was observed that one case in NIG group and two cases in IG group required revision surgery. Furthermore, there were no identifiable predictive factors or differences between the two groups in these re-surgical cases.\u003c/p\u003e\u003cp\u003eIn addition to recurrences, unexpected complications occurred in NIG, with two cases experiencing unforeseen ipsilateral intracranial hemorrhage post-surgery. Both patients in NIG exhibited ipsilateral intracranial hemorrhage on the first postoperative day. No other complications were observed in the IG. Detailed descriptions of these complicated cases are provided separately.\u003c/p\u003e\u003cp\u003eComplicated cases\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eA seventy-three-year-old man came to the emergency department with left-sided weakness and a drowsy mental status. He had a history of hypertension and was taking hypertension medication along with aspirin (100mg daily). The preoperative CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) showed approximately 154.5cc of hematoma, causing midline shift of about 2.07cm and uncal herniation. A frontal burr hole with a catheter was inserted directly without the irrigation of hematoma. A CT scan taken immediately after the surgery showed minimal high density at the right frontal lobe, but the patient had no specific neurological changes. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB)\u003c/p\u003e\u003cp\u003eA day after the surgery, following the drainage of 200cc of hematoma, a brain CT scan was performed, which showed an reduced amount of cSDH to 19.4cc but increase of about 10cc of intracerebral hemorrhage (ICH). (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC) Fortunately, there were no specific neurological deficits aggravated, and the hemorrhage remained stable. The patient's mental status and left-sided weakness improved, and he was discharged 20 days after the surgery.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eA ninety-six-year-old woman came to the clinic with left-sided weakness that had been persisting for a week. Her medical history revealed two head trauma events about 2 weeks prior. She had a history of hypertension, diabetes mellitus, dyslipidemia, asthma, and Alzheimer's disease. She was taking multiple medications; however, there were no antiplatelet or anticoagulants prescribed before. Her preoperative CT showed a chronic subdural hemorrhage on the right side, along with a small amount of subdural hemorrhage in the left frontal area (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eAfter recovering from anesthesia, she exhibited confusion, but her weakness had slightly improved compared to the preoperative state. The postoperative CT showed a well-placed catheter without immediate complications (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB). However, a day after surgery, her left-sided weakness worsened to grade 1. An emergent CT was performed and revealed a massive intracerebral hemorrhage (ICH) in the ipsilateral frontal lobe (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC). Her mental state had slightly improved, but her weakness did not improve, and she was discharged without significant improvement.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChronic subdural hematoma (cSDH) represents a prevalent concern in the field of neurosurgery, particularly among elderly individuals. Burr-hole craniostomy is the established treatment modality for cSDH. Controversies encompass various dimensions, including factors such as sex, age, medical history, the number and locations of burr holes, as well as the utilization of irrigation in management \u003csup\u003e19)\u003c/sup\u003e. This investigation specifically delves into the divergence between irrigation and non-irrigation approaches in the treatment of cSDH. The difference between our irrigated and non-irrigated procedures was primarily determined by the surgeon, with other variables such as subacute hematoma components, antiplatelet usage, and comorbidities remaining relatively consistent.\u003c/p\u003e \u003cp\u003eSeveral factors contribute to the increased incidence of chronic subdural hematoma (cSDH), including advanced age, male gender, and concurrent medical conditions such as hemodialysis or anticoagulant/antiplatelet therapies. However, conclusive evidence substantiating their role in recurrence rates remains lacking. Notably, our study excludes cases of bilateral cSDH, as Ishita et al. highlighted a correlation between bilateral cSDH and an increased recurrence risk \u003csup\u003e14)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eKrupp et al. underscored the importance of patient age and admission condition in the context of chronic subdural hematoma (cSDH) recurrence, suggesting that advanced age and compromised neurological status increase the likelihood of recurrence\u003csup\u003e10,17)\u003c/sup\u003e. However, in our study, there was no significant difference in recurrence rates with increasing age. Frantz et al. conducted a prospective randomized controlled trial to assess the impact of ACE inhibitors, specifically perindopril, on recurrence, but no significant effect was observed \u003csup\u003e16)\u003c/sup\u003e. In contrast, Neidert et al.'s retrospective case-control study revealed elevated hematoma volumes and increased recurrence frequency in patients treated with ACE inhibitors as an adjunct to surgery \u003csup\u003e15)\u003c/sup\u003e. Unfortunately, our study did not analyze the use of ACE inhibitors, but we did analyze patients with hypertension and found no association with an increased risk of recurrence or preventive effect. There are ongoing debates regarding the use of antiplatelet medications in relation to cSDH recurrence. Several previous studies have demonstrated no relationship between the use of drugs affecting hemostasis and recurrence\u003csup\u003e3,4,8)\u003c/sup\u003e. Similarly, we found no significant difference in recurrence with or without antiplatelet use. Preoperative midline shift\u0026thinsp;\u0026ge;\u0026thinsp;10 mm, severe brain atrophy, post-operative severe pneumocephalus, and hematoma drainage volume\u0026thinsp;\u0026ge;\u0026thinsp;100 mL are independent radiographic risk factors for CSDH recurrence \u003csup\u003e1,18)\u003c/sup\u003e. For these factors, we couldn't find the same results as in previous reports, but we can estimate that immediate reduction of midline shift could possibly affect the recurrence rate. Moreover, there are many reports suggesting that post-op pneumocephalus and its volume are reliable factors for recurrence \u003csup\u003e12)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe role of irrigation remains unclear. Some studies have shown no significant differences in the recurrence rates with or without irrigation \u003csup\u003e13,21)\u003c/sup\u003e Numerous investigations indicate comparable efficacy of irrigation and non-irrigation procedures for treating chronic SDH in terms of recurrence outcomes argued that the outcome with or without irrigation is the same in cSDH managed by a drainage system.\u003csup\u003e7,24,26,27)\u003c/sup\u003e. Suzuki and associates reported a recurrence rate of 3.4% for the group without irrigation, and 3% for the group with irrigation. The difference did not reach significance.\u003csup\u003e21)\u003c/sup\u003e In the series by Matsumoto \u003cem\u003eet al\u003c/em\u003e eight of 121 patients had no intraoperative irrigation. There were no significant differences in the recurrence rates.\u003csup\u003e13)\u003c/sup\u003e In Kuroki\u0026rsquo;s series, the recurrence rate was 3.6% without irrigation and 13.3% with irrigation.\u003csup\u003e11)\u003c/sup\u003e Our study corroborates this trend, demonstrating recurrence rates of 16.2% in the Irrigation Group (IG) and 2.3% in the Non-Irrigation Group (NIG). While subdural hematoma irrigation along with the modulation of chemokines within the hematoma may seemingly offer a potential means to reduce recurrence rates, a substantial body of literature suggests that extensive irrigation can engender pneumocephalus within the subdural space \u003csup\u003e6,22)\u003c/sup\u003e. This phenomenon can impede brain expansion, subsequently contributing to recurrent subdural hematoma formation. For summarizing evidences, we could hypothesize that irrigation of SDH while surgery can make pneumocephalus that can impede brain expansion. And those delayed brain expansion can make residual hematoma can format another chronic hematoma and recur. Evidently, non-irrigation emerges as a more effective treatment avenue than irrigation for reducing recurrence rates in cSDH in our study.\u003c/p\u003e \u003cp\u003eFurthermore, we couldn\u0026rsquo;t find significance in recurrence prediction of midline shift reduction, however, reduction rate of midline shift was significantly higher in NIG and that can may because of post operative pneumocephalus due to massive irrigation which seems to impede brain expansion after surgery.\u003c/p\u003e \u003cp\u003eWhile potential biases may be present, unforeseen complications were observed in the NIG. Overdrainage of cSDH may lead to microbleeding due to rapid pressure gradient changes, thereby increasing the risk of ICH \u003csup\u003e2)\u003c/sup\u003e. Since the NIG cannot carefully insert a drainage catheter while observing the brain's surface, there is a possibi\u003csup\u003e4)\u003c/sup\u003elity of serious complications, such as catheter penetration of the cerebral cortex, leading to ICH and related issues. While we are not certain why these serious complications occurred, it's worth noting that both patients were taking antiplatelet agents, specifically cilostazol and\u003csup\u003e3)\u003c/sup\u003e clopidogrel, which may increase their risk of hemorrhage compared to others. Consequently, we advise surgeons to exercise caution when considering rapid drainage in cases of non-irrigated hematoma in order to mitigate the risk of ICH.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003ePatients were randomly assigned to surgeons who utilized distinct surgical techniques. However, the uneven distribution of patients between the Irrigation Group (IG) and the Non-Irrigation Group (NIG) (44 vs. 37), coupled with the low recurrence rates, could potentially undermine the robustness of the findings. Categorizing the surgical methods into two broad groups, hematoma irrigation or non-irrigation, may obscure potential nuances stemming from variations in individual surgical practices, which could also impact surgical outcomes.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study highlights significant differences between the two groups. However, given the small recurrence rate in relation to the total number of surgeries, and the fact that only one case in each group required revision surgery, statistical analysis couldn't be performed with precision. Therefore, further studies with larger cohorts are necessary to obtain more conclusive results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn our investigation, extensive irrigation for cSDH exhibited a potential association with heightened recurrence rates compared to the non-irrigation approach of simple drainage. Furthermore, aside from the recurrence aspect, unexpected and severe intracerebral hemorrhagic complications emerged within the NIG. Although a causal link remains speculative, the occurrence warrants further scrutiny. The complexity of these findings underscores the necessity for rigorous high-quality randomized controlled trials to delve into this matter more comprehensively.\u003c/p\u003e \u003cp\u003eDuring the preparation of this work the authors used ChatGPT, an AI language model developed by OpenAI in order to enhance the article's readability by ensuring grammatical correctness and providing readers with the intended information. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHSC : Conceptualization; Data curation; Formal analysis; Writing original draftHSL : Data curation; Statistical analysisYSJ : Data curation; Editing original draftWHL : Data curation; Editing original draft; Supervision; ValidationKRC : Conceptualization; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Data curation; Formal analysis; Writing and editing original draft;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlmenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, et al. : Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. \u003cstrong\u003eAnn Surg\u003c/strong\u003e \u003cstrong\u003e259\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 449-457, 2014\u003c/li\u003e\n\u003cli\u003eAn SJ, Kim TJ, Yoon BW : Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. \u003cstrong\u003eJ Stroke\u003c/strong\u003e \u003cstrong\u003e19\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 3-10, 2017\u003c/li\u003e\n\u003cli\u003eChoi J, Pyen J, Cho S, Kim J, Koo Y, Whang K : Influence of Antithrombotic Medication on the Risk of Chronic Subdural Hematoma Recurrence after Burr-Hole Surgery. \u003cstrong\u003eJ Korean Neurosurg Soc\u003c/strong\u003e \u003cstrong\u003e63\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 513-518, 2020\u003c/li\u003e\n\u003cli\u003eDe Bonis P, Trevisi G, de Waure C, Sferrazza A, Volpe M, Pompucci A, et al. : Antiplatelet/anticoagulant agents and chronic subdural hematoma in the elderly. \u003cstrong\u003ePLoS One\u003c/strong\u003e \u003cstrong\u003e8\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e e68732, 2013\u003c/li\u003e\n\u003cli\u003eFeghali J, Yang W, Huang J : Updates in Chronic Subdural Hematoma: Epidemiology, Etiology, Pathogenesis, Treatment, and Outcome. \u003cstrong\u003eWorld Neurosurg\u003c/strong\u003e \u003cstrong\u003e141\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 339-345, 2020\u003c/li\u003e\n\u003cli\u003eGuo X, Wu L, Ou Y, Yu X, Zhu B, Yang C, Liu W : Postoperative pneumocephalus and recurrence and outcome of chronic subdural hematoma: a systematic review and meta-analysis. \u003cstrong\u003eNeurosurg Rev\u003c/strong\u003e \u003cstrong\u003e46\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 13, 2022\u003c/li\u003e\n\u003cli\u003eIftikhar M, Siddiqui UT, Rauf MY, Malik AO, Javed G : Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma. \u003cstrong\u003eJ Neurol Surg A Cent Eur Neurosurg\u003c/strong\u003e \u003cstrong\u003e77\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 416-421, 2016\u003c/li\u003e\n\u003cli\u003eKamenova M, Lutz K, Schaedelin S, Fandino J, Mariani L, Soleman J : Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates? \u003cstrong\u003eNeurosurgery\u003c/strong\u003e \u003cstrong\u003e79\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 715-721, 2016\u003c/li\u003e\n\u003cli\u003eKolias AG, Chari A, Santarius T, Hutchinson PJ : Chronic subdural haematoma: modern management and emerging therapies. \u003cstrong\u003eNat Rev Neurol\u003c/strong\u003e \u003cstrong\u003e10\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 570-578, 2014\u003c/li\u003e\n\u003cli\u003eKrupp WF, Jans PJ : Treatment of chronic subdural haematoma with burr-hole craniostomy and closed drainage. \u003cstrong\u003eBr J Neurosurg\u003c/strong\u003e \u003cstrong\u003e9\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 619-627, 1995\u003c/li\u003e\n\u003cli\u003eKuroki T, Katsume M, Harada N, Yamazaki T, Aoki K, Takasu N : Strict closed-system drainage for treating chronic subdural haematoma. \u003cstrong\u003eActa Neurochir (Wien)\u003c/strong\u003e \u003cstrong\u003e143\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 1041-1044, 2001\u003c/li\u003e\n\u003cli\u003eLiu W, Bakker NA, Groen RJ : Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. \u003cstrong\u003eJ Neurosurg\u003c/strong\u003e \u003cstrong\u003e121\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 665-673, 2014\u003c/li\u003e\n\u003cli\u003eMatsumoto K, Akagi K, Abekura M, Ryujin H, Ohkawa M, Iwasa N, Akiyama C : Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage. \u003cstrong\u003eNeurol Res\u003c/strong\u003e \u003cstrong\u003e21\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 277-280, 1999\u003c/li\u003e\n\u003cli\u003eMiah IP, Tank Y, Rosendaal FR, Peul WC, Dammers R, Lingsma HF, et al. : Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. \u003cstrong\u003eNeuroradiology\u003c/strong\u003e \u003cstrong\u003e63\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 27-40, 2021\u003c/li\u003e\n\u003cli\u003eNeidert MC, Schmidt T, Mitova T, Fierstra J, Bellut D, Regli L, et al. : Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: Associations with initial presentation and clinical outcome. \u003cstrong\u003eJ Clin Neurosci\u003c/strong\u003e \u003cstrong\u003e28\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 82-86, 2016\u003c/li\u003e\n\u003cli\u003ePoulsen FR, Munthe S, Soe M, Halle B : Perindopril and residual chronic subdural hematoma volumes six weeks after burr hole surgery: a randomized trial. \u003cstrong\u003eClin Neurol Neurosurg\u003c/strong\u003e \u003cstrong\u003e123\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 4-8, 2014\u003c/li\u003e\n\u003cli\u003eRauhala M, Luoto TM, Huhtala H, Iverson GL, Niskakangas T, Ohman J, Helen P : The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population. \u003cstrong\u003eJ Neurosurg\u003c/strong\u003e \u003cstrong\u003e132\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 1147-1157, 2019\u003c/li\u003e\n\u003cli\u003eShen J, Yuan L, Ge R, Wang Q, Zhou W, Jiang XC, Shao X : Clinical and radiological factors predicting recurrence of chronic subdural hematoma: A retrospective cohort study. \u003cstrong\u003eInjury\u003c/strong\u003e \u003cstrong\u003e50\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 1634-1640, 2019\u003c/li\u003e\n\u003cli\u003eSolou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, et al. : Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. \u003cstrong\u003eDiagnostics (Basel)\u003c/strong\u003e \u003cstrong\u003e12\u003c/strong\u003e, 2022\u003c/li\u003e\n\u003cli\u003eSucu HK, Gokmen M, Gelal F : The value of XYZ/2 technique compared with computer-assisted volumetric analysis to estimate the volume of chronic subdural hematoma. \u003cstrong\u003eStroke\u003c/strong\u003e \u003cstrong\u003e36\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 998-1000, 2005\u003c/li\u003e\n\u003cli\u003eSuzuki K, Sugita K, Akai T, Takahata T, Sonobe M, Takahashi S : Treatment of chronic subdural hematoma by closed-system drainage without irrigation. \u003cstrong\u003eSurg Neurol\u003c/strong\u003e \u003cstrong\u003e50\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 231-234, 1998\u003c/li\u003e\n\u003cli\u003eSuzuki M, Endo S, Inada K, Kudo A, Kitakami A, Kuroda K, Ogawa A : Inflammatory cytokines locally elevated in chronic subdural haematoma. \u003cstrong\u003eActa Neurochir (Wien)\u003c/strong\u003e \u003cstrong\u003e140\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 51-55, 1998\u003c/li\u003e\n\u003cli\u003eTamura R, Sato M, Yoshida K, Toda M : History and current progress of chronic subdural hematoma. \u003cstrong\u003eJ Neurol Sci\u003c/strong\u003e \u003cstrong\u003e429\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 118066, 2021\u003c/li\u003e\n\u003cli\u003eWeigel R, Schmiedek P, Krauss JK : Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. \u003cstrong\u003eJ Neurol Neurosurg Psychiatry\u003c/strong\u003e \u003cstrong\u003e74\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 937-943, 2003\u003c/li\u003e\n\u003cli\u003eWon SY, Zagorcic A, Dubinski D, Quick-Weller J, Herrmann E, Seifert V, Konczalla J : Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. \u003cstrong\u003ePLoS One\u003c/strong\u003e \u003cstrong\u003e13\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e e0199809, 2018\u003c/li\u003e\n\u003cli\u003eXu C, Chen S, Yuan L, Jing Y : Burr-hole Irrigation with Closed-system Drainage for the Treatment of Chronic Subdural Hematoma: A Meta-analysis. \u003cstrong\u003eNeurol Med Chir (Tokyo)\u003c/strong\u003e \u003cstrong\u003e56\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e 62-68, 2016\u003c/li\u003e\n\u003cli\u003eYuan Y, Wang QP, Cao YL, Zhang H, Burkutally MSN, Budryte K, Xiong N : Burr hole drainage and burr hole drainage with irrigation to treat chronic subdural hematoma: A systematic review and meta-analysis. \u003cstrong\u003eMedicine (Baltimore)\u003c/strong\u003e \u003cstrong\u003e97\u003c/strong\u003e \u003cstrong\u003e:\u003c/strong\u003e e11827, 2018\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"chronic subdural hemorrhage, burrhole, Craniostomy, irrigation, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-4279392/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4279392/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCSDH is often treated with surgical blood drainage, but concerns about recurrence and outcomes persist. Surgical techniques, including irrigation, vary. This study compares the outcomes of irrigation in cSDH surgery.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eFrom September 2020 to September 2022, 92 cSDH patients underwent surgery. Two different irrigation methods were used: extensive irrigation (IG) and non-irrigation (NIG). Method of irrigation was selected by each surgeon\u0026rsquo;s preference. Parameters measured included volume of hematoma changes, midline shifting, complications, and basic demographics. Recurrence was defined as symptomatic or hematoma expansion more than double the volume before surgery. Factors predicting recurrence and irrigation method impact were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEleven patients were excluded because of bilateral or related to other disease. We analyzed 81 patients (44 NIG, 37 IG). Recurrence occurred in 6 IG cases (16.2%) and 1 NIG case (2.3%). Irrigation method significantly affected recurrence (P\u0026thinsp;=\u0026thinsp;0.043). Age, gender, medication, medical history, and preoperative measurements had no major impact on recurrence. NIG had unexpected cases of intracerebral hemorrhage.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eExtensive irrigation may increase recurrence in cSDH drainage. Non-irrigation drainage had fewer recurrences, but unexpected complications arose. Careful drainage in non-irrigated cases is crucial.\u003c/p\u003e","manuscriptTitle":"Comparative Clinical Outcomes of Irrigation Techniques in Burr-Hole Craniostomy for Chronic Subdural Hemorrhage: A Multicenter Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 14:30:53","doi":"10.21203/rs.3.rs-4279392/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-08T07:25:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-03T18:50:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-01T11:37:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"644120b0-ba54-4fa8-95f3-5a95caee9121","date":"2024-04-21T18:36:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6ce3f0b2-620a-4484-9a65-215c926eefc5","date":"2024-04-20T18:39:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-20T16:13:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-20T16:09:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-18T06:06:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-04-17T05:10:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"746c547e-66c8-4f7b-a3e9-eccab8bbd625","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-07-02T00:35:53+00:00","versionOfRecord":{"articleIdentity":"rs-4279392","link":"https://doi.org/10.1007/s00068-024-02586-9","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2024-07-01 00:35:53","publishedOnDateReadable":"July 1st, 2024"},"versionCreatedAt":"2024-04-29 14:30:53","video":"","vorDoi":"10.1007/s00068-024-02586-9","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02586-9","workflowStages":[]},"version":"v1","identity":"rs-4279392","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4279392","identity":"rs-4279392","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}