Clinical study

Early post-operative seizures after burr-hole drainage for

chronic subdural hematoma: correlation with brain CT
ndings
Chih-Wei Chen MD MD, , Jinn-Rung Kuo MD MD, , Hung-Jung Lin MD MD, , Chao-Hung Yeh MD MD, , Bing-Sang Wong MD MD, ,
Cheng-Hsing Kao MD MD, , Chung-Ching Chio MD MD
Division of Neurosurgery, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
Summary The incidence of seizures in patients undergoing burr-hole crainiostomy with closed-system drainage for chronic subdural hema-
toma (CSDH) is low. The post-operative use of anticonvulsants is, thus, controversial. In this study, we tried to correlate pre-operative
computed tomographic (CT) appearance of the CSDH with the need for post-operative seizure prophylaxis. From April 1998 to November 2001,
128 cases of CSDH surgically treated at our hospital were studied. All patients underwent burr-hole craniostomy with closed system drainage.
All CSDHs were classied as low-density, isodense, and mixed-density lesions according to CT ndings. The incidence of early post-operative
seizures (within 3 weeks of surgery) among all patients was 5.4% (7/128). In the subgroups by lesion density, the incidences were 6.2% (1/16)
in the low-density group, 2.4% (2/83) in the isodense group, and 13.7% (4/29) in the mixed-density group (all p < 0:05). The mean age among
the seven patients (ve males and two females) who had seizures was 71 years. The locations of the CSDHs among the 128 patients were the
left side of the brain in 53 (41.4%) patients, right side in 45 (35.2%), and bilateral in 30 (23.4%) patients. Among the seven patients who suffered
from post-operative seizures, ve (71.4%) had left side CSDHs, one (14.2%) had a right side CSDH, and one (14.2%) had bilateral CSDHs. We
concluded that the post-operative seizure rate appeared high in the group with mixed-density type lesions on CT, and in those with left unilateral
CSDH. We suggest the use of prophylactic anticonvulsants for patients with mixed-density lesions on pre-operative CT.
2004 Elsevier Ltd. All rights reserved.
Keywords: chronic subdural hematoma, burr-hole drainage, post-operative seizure, antiepileptic prophylaxis
INTRODUCTION
Chronic subdural hematoma (CSDH) is a common disease in our
daily practice. The predisposing factors include head trauma,
chronic alcoholism, seizure disorders, shunt procedures following
hydrocephalus, brain atrophy, and coagulopathy.
13
The best and
simplest method of treatment for CSDH is burr-hole crainiostomy
with post-operative closed-system drainage.
4;5
The occurrence of seizures immediately or during the 2 weeks
after burr holes with post-operative closed-system drainage has
been well recognized. The incidence of seizure in patients re-
ceiving burr-hole drainage for CSDH is reported to be about 5%
(Hirakawa et al.,
6
5.3%; Kotwica and Brzezinski,
7
5.4%). Thus,
the prophylactic use of antiepileptic agents among patients after
burr-hole surgery is controversial.
Computed tomography (CT) is the most useful tool for the
evaluation of CSDH. On CT study, CSDH may have density
values of low (similar to CSF), intermediate (similar to gray
matter), or mixed type.
8
In this study, we tried to determine if the
pre-operative CT appearance of CSDH correlated with post-op-
erative seizure activity to justify the use of prophylactic anticon-
vulsant therapy in some CSDH subgroups.
CLINICAL MATERIALS AND METHODS
From April 1998 to November 2001, 128 patients with CSDH
surgically treated at our hospital were studied. All the patients
underwent burr-hole craniostomy with closed-system drainage for
CSDH. The diagnosis of CSDH was confirmed by the typical
neomembranes and liquefied blood during surgery. Brain CT
scans were performed on the day before or the day of surgery and
the CSDHs were classified as low-density, isodense, and mixed-
density lesions (Fig. 1).
9
No anticonvulsant was administered
before or after burr-hole craniostomy unless there was evidence of
seizure. For patients who developed early post-operative seizures,
phenytoin was used for controlling the seizures.
For statistical analysis, Fisher's exact test for independence
was performed.
RESULTS
Among the 128 patients, there were 95 men and 33 women (male/
female ratio, 2.8:1) whose ages ranged from 23 to 93 years, with
an average age of 67 years. The pre-operative CT findings showed
that 16 patients had low-density CSDHs, 83 had isodense CSDHs,
and 29 had mixed-density CSDHs (Table 1). The isodense type
had the highest prevalence rate (65%, 83/128).
Seven (5.4%) of the 128 patients developed seizures within 3
weeks after the operation. Their mean age was 71 years; five were
men and two were women (male/female ratio, 2.5:1). Five (71%)
of the seven patients suffered from seizures within 3 days after
surgery. In four (57%) of the seven patients, the seizures were of
the generalized tonic-clonic type; the other three patients (43%)
had partial seizures with motor symptoms (Table 2).
Among the seven patients with early post-operative seizures,
pre-operative CT showed low-density CSDHs in 6.2% (1/16),
Journal of Clinical Neuroscience (2004) 11(7), 706709
0967-5868/$ - see front matter 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocn.2004.03.019
Received 3 June 2003
Accepted 27 March 2004
Correspondence to: Chung-Ching Chio MD, Division of Neurosurgery,
Department of Surgery, Chi-Mei Medical Center, 901, Chung Hwa Road,
Yung Kang City, Tainan 710, Taiwan. Tel.: +886-6-281-2811/9394;
Fax: +886-6-282-8928/0404;
E-mail: [email protected]
706
isodense CSDHs in 2.4% (2/83), and mixed-density CSDHs in
13.7% (4/29). The post-operative seizure rate was high in the
mixed-density group findings indicative of recent hemorrhage
(p < 0:05).
Among the 128 patients, 53 (41.4%) had CSDHs on the left
side of the brain, 45 (35.2%) had CSDHs on the right side, and 30
(23.4%) had bilateral CSDH (Table 3). Among the seven patients
who suffered from post-operative seizures, there were five
(71.4%) with left side CSDHs, one (14.2%) with a right side
CSDH, and one (14.2%) with bilateral CSDHs. Early post-oper-
ative seizure also had a high incidence in patients with left uni-
lateral CSDH, based on pre-operative CT findings.
DISCUSSION
Subdural hematomas between 3 days and 3 weeks old are con-
sidered to be subacute.
10
After 23 weeks, these subacute subdural
hematomas are considered to be chronic.
11
Subdural hematomas
were found to be isodense on CT in 70% of the subacute group
and were of low density in 70% of the chronic group.
12
Kostanian
et al.,
9
divided 84 CSDHs into three major groups according to
pre-operative CT density values. They reported that 61 (71%)
were low-density, nine (13%) were isodense, and 14 (16%) were
mixed-density lesions, with the low-density type having the
highest prevalence (71%). However, Lee et al.,
13
in Korea, re-
ported that the isodense type had the highest prevalence rate
(86.7%) in their study. In our study, 16 (12%) of the CSDHs were
low-density lesions, 83 (65%) were isodense, and 29 (23%) were
mixed-density lesions, with most of the patients having the iso-
dense type. One possible explanation for these differences in
CSDH density may be due to race differences. Another possible
reason may be due to different definitions of isodense and low
density for CT findings. In addition, the isodense type is difficult
to diagnose, especially in the case of bilateral CSDHs.
The CSDHs in our 128 patients were found bilaterally in 30
(24%) patients, in the left side of the brain in 53 (41%) patients,
and in the right side in 45 (35%) patients. Smely et al.
25
reported
that of 66 patients with CSDHs, 10 (15.3%) had bilateral CSDHs,
32 (48.4%) had left unilateral, and 24 (36.3%) patients had right
unilateral CSDHs. In our study, among the seven patients who
suffered from post-operative seizures, the CSDHs were in the left
side of the brain in five (71.4%) patients, the right side in one
(14.2%), and were bilateral in one (14.2%). These data suggest
that early post-operative seizures occurred more frequently in
patients with left unilateral CSDHs, based on pre-operative CT
findings.
The attenuation of the CSDHs as seen on CT correlated with
their macroscopic appearance. Low-density hematomas are typi-
cally golden yellow or bile colored on CT, isodense hematomas
are cherry red or reddish brown, and mixed-density hematomas
are reddish brown with soft fresh clots.
14
The microscopic features
of mixed-density CSDHs reveal many fresh erythrocytes, and
higher fibrinogen composition,
8
indicating recurrent hemor-
rhage.
15;16
The concentration of tissue plasminogen activator
(t-PA) is highest and the concentration of plasminogen activator
inhibitor (PAI) is lowest in mixed-density CSDHs.
17
This suggests
that fibrinolytic activity is highest in mixed-density CSDHs. High-
molecular weight fibrin degradation products (FDPs) inhibit
coagulation, platelet aggregation, fibrin polymerization, and pro-
mote the activity of t-PA.
17
The FDPs also have angiogenic ac-
tivity and stimulate fibroblast proliferation, possibly contributing
to CSDH membrane formation.
18
The FDP level is highest in the
mixed-density group. CSDHs are thought to form in the layer of
dural border cells in the hematoma cavity that is surrounded by
outer and inner membranes.
19
There are few blood vessels in the
inner membrane,
20
whereas the outer membrane contains many
fragile sinusoidal vessels that often are the source of repeated
multifocal bleeding.
1921
The outer membrane has higher vascular
congestion and vascular permeability.
22;23
Kotwica and Brzezinski
7
suggest that the capsule of the CSDH
plays an important role in the incidence of seizure after surgical
Fig. 1 Computerized tomography demonstrating examples of three types of
chronic subdural hematomas: isodense (A), low-density (B), and mixed-
density (C).
Table 1 Pre-operative computed tomography (CT) ndings in 128 total
cases and seven post-operative seizure cases of chronic subdural hematoma
Pre-operative CT
ndings
Low-density Isodense Mixed-density Total
Total patients 16 83 29 128
Post-operative
seizure patients
1 2 4 7
Early post-operative seizures after burr-hole drainage for chronic subdural hematoma 707
2004 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(7), 706709
treatment of CSDH. How to explain the highest incidence of post-
operative seizures occurred in the mixed-density group? The
possible mechanism is that higher FDP concentration levels pass
through the higher permeability of the CSDH outer membrane to
influence the brain parenchyma to induce a seizure. The volumes
of CSDHs on brain CT were largest among mixed-density
CSDHs.
17
Kwon et al.
24
reported that mixed-density CSDHs had
the lowest mean post-operative drainage volume of 151 86 ml
compared with 413 269 ml for low-density and 348 257 ml for
isodense CSDHs. This indicates that mixed-density lesions oc-
cupied larger spaces and had larger mass effects on brain paren-
chyma. This may be another mechanism for mixed-density
CSDHs having the highest incidence of post-operative seizures.
In our seven cases of post-operative seizure, five (71.4%) pa-
tients suffered from seizures within 3 days after surgery, while the
longest time to seizure was 20 days post-surgically. After a post-
operative seizure was noted, phenytoin was used for seizure
control for 6 months. No further seizures were noted after 6
months of follow-up. Kotwica and Brzezinski,
7
reported that the
seven patients who suffered from post-operative seizures among
122 patients with CSDHs had good early results with anticon-
vulsant therapy.
In our study, the incidence of post-operative seizure (5.4%) was
similar to that of other reports.
2628
The real effectiveness of an-
tiepileptic prophylaxis to reduce the occurrence of post-operative
seizure is controversial. Sabo et al.
29
reported that post-operative
seizures occurred in 1 of 42 (2.4%) patients who received antiep-
ileptic prophylaxis and in 16 of 50 (32%) patients who did not
receive antiepileptic prophylaxis p < 0:001. Thus, they recom-
mended the use of phenytoin prophylaxis for patients treated sur-
gically for CSDH. Nonetheless, Rubin and Rappaport
30
reported
post-operative seizures in 4.8% (4/83) of the patients treated with
antiepileptic prophylaxis, compared with only 3.4% (2/55) of those
who did not receive medication. They, therefore, did not recom-
mend antiepileptic prophylaxis. Prophylactic anticonvulsant ther-
apy is generally recommended when the risk of seizure exceeds
from 10% to 15%.
31;32
In our study, early post-operative seizures
occurred in 13.7% (4/29) of mixed-density CSDHs, based on pre-
operative CT. Thus, we suggest prophylaxis for post-operative
seizures in patients with mixed-density CSDHs.
CONCLUSIONS
In this study and in a review the literature, the incidence of post-
operative seizure after burr-hole drainage for CSDH was very low.
Nonetheless, the post-operative seizure rate was relatively high
among patients with mixed-density CSDHs, based on pre-opera-
tive CT. Although the real effectiveness of antiepileptic prophy-
laxis to reduce the occurrence of post-operative seizure is
controversial, we propose the addition of at least short-term
antiepileptic prophylaxis with phenytoin for patients with mixed-
density CSDHs on pre-operative CT. It seemed that early post-
operative seizures also had a high incidence among patients with
left unilateral CSDHs based on pre-operative CT finding.
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Table 3 Chronic subdural hematoma location and density in 128 cases
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CT, computed tomography.
Table 2 Summary of seven post-operative seizure cases
Age (years) Sex Time to seizure onset Seizure type Pre-operative CT ndings
73 Male 20 days Focal Left, mixed-density
60 Male 16 h Generalized Bilateral, isodense
86 Male 7 h Generalized Left, low-density
74 Male 3 days Focal Right, isodense
73 Male 1 day Focal Left, mixed-density
65 Female 2 days Generalized Left, mixed-density
72 Female 10 days Generalized Left, mixed-density
CT, computed tomography.
708 Chen et al.
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2004 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(7), 706709