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Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Chronic subdural hematoma enhanced recovery pathway: targeting excellent outcomes
Srujana Venkata Vedicherla1, Zakir Hassan Chew1, Dave Thevandiran Kanavathy1
11Department of Neurosurgery, National Neuroscience Institute, Singapore.
Insights
Implementing an enhanced recovery pathway for chronic subdural hematoma (cSDH) surgery significantly reduced hospital length of stay and improved patient discharge destinations. This standardized care approach increased excellent outcomes for cSDH patients.
Area of Science:
- Neurosurgery
- Evidence-based medicine
Background:
- Chronic subdural hematoma (cSDH) presents a common neurosurgical challenge.
- Current surgical outcomes for cSDH, including recurrence and complication rates, require improvement.
Purpose of the Study:
- To design and implement an enhanced recovery pathway for cSDH.
- To evaluate the impact of this pathway on surgical outcomes.
Main Methods:
- A multicenter cohort study compared outcomes before and after pathway implementation.
- Patient data included demographics, clinical and radiological details.
- Outcome measures: length of stay (LOS), complications, discharge location, mortality, and recurrence.
Main Results:
- The post-pathway group showed a shorter median LOS (7 vs 9 days) and higher likelihood of discharge to home/rehab.
- Excellent outcomes increased from 34.7% to 49.7% post-pathway.
- Recurrence rates decreased, though not significantly (11.8% to 7.7%).
Conclusions:
- Standardizing care via an enhanced recovery pathway improves LOS and discharge outcomes for cSDH.
- This approach increases the proportion of patients achieving excellent outcomes.
- Further research may explore strategies to significantly reduce recurrence rates.
Objective:
Chronic subdural hematoma (cSDH) is one of the most common neurosurgical pathologies. Despite the optimization of surgical approaches, outcomes such as recurrence and complication rates remain unacceptably high. Consolidated evidence-based pathways have demonstrated a clear impact on surgical outcomes. Herein, the authors aggregated literature evidence and institutional experience to design and implement an enhanced recovery pathway for cSDH.
Methods:
A multicenter cohort study was conducted over two periods: prior to (July 2021 to June 2022) and after (July 2022 to June 2023) pathway implementation. All adult patients with surgically evacuated cSDH or subacute subdural hematoma (SDH) were included in the study. Patients with SDHs that were managed conservatively, acute SDH treated with craniotomy or craniectomy, or subdural empyemas were excluded. Demographic details as well as preoperative clinical and radiological data were collected. Outcome measures included hospital length of stay (LOS), complication rate, discharge location, 30-day mortality, and 3-month recurrence. An excellent outcome was defined as discharge within a week of burr hole evacuation to a location similar to or better than premorbidly and no 3-month recurrence.
Results:
One hundred seventy prepathway and 169 postpathway patients were included in the final analysis and were comparable both demographically and clinically. After multivariable logistic regression analysis, the postpathway group had a shorter median LOS (9 vs 7 days, p = 0.003) and were more likely to be discharged to home or a rehabilitation facility (OR 2.77, 95% CI 1.45-5.56, p = 0.002). The 3-month recurrence rate reduced from 11.8% prepathway to 7.7% postpathway, although the difference between the two was not statistically significant (p = 0.13). Excellent outcomes were more likely postpathway, increasing from 34.7% to 49.7% (OR 1.92, 95% CI 1.19-3.13, p = 0.008).
Conclusions:
The treatment of cSDH is ever evolving with newer adjuncts and treatment modalities described in the literature. However, with the simple standardization of care in patients with cSDH, a reduced LOS, an optimized patient discharge location, and an increase in the proportion of patients with excellent outcomes were noted.
