Comparison between the use of subdural and subgaleal drainage in treatment of chronic subdural hematoma

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=> "María Ángeles" "apellidos" => "García Pallero" ] 2 => array:2 [ "nombre" => "Cristian Leonardo" "apellidos" => "Ortiz Alonso" ] 3 => array:2 [ "nombre" => "Celia" "apellidos" => "González Moldes" ] 4 => array:2 [ "nombre" => "Cristina" "apellidos" => "Ferreras García" ] 5 => array:2 [ "nombre" => "Belén" "apellidos" => "Álvarez Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Neurocirugía, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación entre el uso de drenaje subdural y subgaleal en tratamiento del hematoma subdural crónico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1078 "Ancho" => 1650 "Tamanyo" => 72057 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Bar chart of the complications analysis." ] ] ] "textoCompleto" => "IntroductionChronic subdural haematoma (CSH) is characterised by an accumulation of blood products in the subdural space<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> and is one of the most common conditions seen in the daily practice of neurosurgeons.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>Its incidence ranges from 1.76 to 20.6 cases per 100,000 population and is significantly higher in older adults.<a class="elsevierStyleCrossRefs" href="#bib0005">1,5,6</a> Given that the most important risk factor for the development of CSDH is head injury and that the size of the older adult population is increasing, CSDH evacuation is expected to become the most commonly performed surgical intervention in neurosurgery departments in the USA in 2030.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Surgical evacuation of CSDH is the standard treatment. Evacuation can be performed in several ways: by craniotomy, standard burr hole or mini-burr hole with twist drill.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> In addition, placement of a subdural drain following burr hole drilling has been shown to decrease the recurrence rate of CSDH. However, this procedure carries risks such as damage to the brain parenchyma, infection and seizures. For this reason, subgaleal drainage is proposed as an alternative.<a class="elsevierStyleCrossRefs" href="#bib0040">8,10</a>HypothesisThe placement of a subgaleal drain in the treatment of CSDH could be an alternative to subdural drainage, with the same safety and efficacy.Objectives<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1To analyse and compare complications after placement of a subgaleal drain and a subdural drain in the treatment of CSDH.</li><li class="elsevierStyleListItem" id="lsti0010">2To analyse and compare CSDH recurrence after placement of a subgaleal drain and a subdural drain.</li></ul>MethodologyDesignWe conducted a retrospective observational study which analysed a series of patients diagnosed with CSDH and treated surgically at our centre from January 2020 to April 2022.To obtain the data, the medical records of patients with this diagnosis were reviewed and a series of variables were collected which are detailed below. Patients were subsequently assigned to one of two groups, depending on whether they were treated with subgaleal drainage or subdural drainage, in order to identify any differences between the two.Study populationThe study included patients over 18 years of age with a diagnosis of CSDH whose haematoma was surgically evacuated using the burr hole or mini-burr hole approach, and in whom either a subgaleal or subdural drain was placed. The placement of a either a subgaleal or subdural drain was at the discretion of the neurosurgeon performing the operation.The exclusion criteria were CSDH which were not treated surgically or which, despite being evacuated, were not drained.VariablesA total of 20 variables were collected including age, gender, history of traumatic brain injury, history of taking antiplatelet or anticoagulant medication, use of corticosteroids as part of medical treatment, Markwalder grading scale, haematoma thickness on admission and postoperative CT scan, midline shift, symptoms on admission, Glasgow coma scale on admission and discharge, number of days of admission, time in hours from diagnosis to surgery, type of surgery, type of drainage used, CSDH recurrence or not, type of treatment after recurrence, time to recurrence and post-surgical complications.Recurrence was defined as symptoms related to the same haematoma and requiring readmission at least four weeks after the first surgical intervention. All complications attributable to surgery, such as surgical site infection, haemorrhage and seizures, were included.Patient management protocolAll patients included in the study followed the same protocol used in our centre for patients undergoing CSDH surgery, which includes antibiotic prophylaxis with cefazolin 2 g/every 8 h (or vancomycin 2 g/every 12 h in case of allergy to beta-lactam antibiotics) for the duration of the drain being in situ. Subdural drainage is maintained for 24 h without vacuum and subgaleal drainage is maintained for 48 h, with vacuum, regardless of the output obtained. In addition, all patients undergo a postoperative brain CT scan prior to discharge 24−72 h after surgery.Ethical considerationsThis study was approved by the University Central Hospital of Asturias Independent Ethics Committee, and the guidelines of the Declaration of Helsinki were followed.Statistical modelsData were analysed using IBM® SPSS® Statistics version 25. After checking the normality of the quantitative variables using the Kolmogorov-Smirnov test, statistically significant differences were looked for in the distribution of the different variables according to the type of drainage the patients received. The Student's t-test and Mann-Whitney test were used for quantitative variables and the Chi-square test and Fisher's exact test for qualitative variables. Statistical significance was established at a P-value <.05.ResultsA total of 152 patients were analysed, of which 80 had a subdural drain and 72 a subgaleal drain. The mean age of the sample was 78.7 years (SD: 10.5), 61.8% of the patients were male, 53.3% had a history of previous traumatic brain injury (TBI) and 52.6% received corticosteroid therapy. In terms of haematoma characteristics, the mean haematoma thickness was 22.4 mm (SD: 6.8) and the mean midline shift was 8.4 mm (SD: 4.7). The mean length of hospital stay was 9.4 days (SD: 6.7) and the mean time to surgery was 68.8 h (SD: 94.9). Some 30.9% of patients were on anticoagulants, while 20.4% of patients were on antiplatelet agents. The most common symptom was headache, reported in 27% of patients, followed by gait instability in 25.7% and limb weakness in 22.4%. Some 58.6% of patients had a Markwalder grading scale score of 1 and 60.5% of patients had a Glasgow Coma Scale score of 15 points.Patients were assigned to one of two groups, depending on whether they were treated with subgaleal drainage or subdural drainage, and the two groups were compared for homogeneity. First, a descriptive analysis of the demographic and clinical variables that could act as confounding factors was performed. The only variable for which statistically significant differences were found was midline shift (P = .005), with a value of 9.4 mm recorded for subdural drainage patients compared to 7.2 mm for subgaleal drainage patients. For this reason, a multivariate analysis of midline shift was performed, ruling out that it acted as a confounding factor for both the recurrence analysis (P = .252) and the development of complications (P = .889). For the remaining variables, no statistically significant differences were found between the two groups.The distribution of variables and the comparison between patients given subdural and subgaleal drainage are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Analysis of recurrenceIn the group of patients given subdural drainage, 24 had a recurrence, accounting for 30% of the total. In the group of patients given subgaleal drainage, 15 had a recurrence, accounting for 20.83% of the total. These results were analysed using Fisher's exact test, with no statistically significant differences (P = .134). A summary of the data can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In addition, the odds ratio was calculated for these two variables, obtaining a result of 0.58 with a 95% confidence interval (0.28–1.21), which therefore also failed to reach statistical significance.Of the 39 patients who had a recurrence, 82.1% (32 patients) underwent further surgery, compared to 17.9% (7 patients) in whom a conservative treatment approach was followed. In the subgroup of patients who suffered recurrence, we also analysed the type of treatment they received after recurrence (surgical vs conservative) and the type of drain placed in the initial surgery using Fisher's exact test, without finding significant differences (P = .444).The mean time to recurrence for all patients was 6.7 weeks (SD: 4.4), with no significant differences in this variable between the two subgroups according to the type of drainage (P = .467).Analysis of complicationsComplications occurred in six patients in the subdural drainage group, 7.5% of the total. In the subgaleal drainage group, complications occurred in four patients, accounting for 5.5% of the total. The results were analysed with Fisher's exact test and no statistically significant differences were found (P = .749). A summary of the data can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In addition, the odds ratio was calculated for these two variables, yielding a result of 0.73 with a 95% confidence interval (0.20–2.68), which therefore also failed to reach statistical significance.Of the total number of complications, only two (1.3%), were directly related to the procedure. The rest were systemic infections, urological infections, lower gastrointestinal bleeding or death due to causes other than CSDH. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> details the number and type of complications in the cohort.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionAlthough surgical evacuation is the established gold standard for the treatment of CSDH, there is less clarity on the surgical technique to be used, as several ways of evacuating this type of haematoma have been described, from large craniotomies to endoscopic techniques,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> with or without the addition of various types of drain.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> The trend in recent years has been towards increasingly less invasive treatment.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>This study analysed the use of subdural versus subgaleal drainage, regardless of the type of surgery performed to evacuate the haematoma, without finding statistically significant differences either in recurrence or in the development of complications.RecurrenceThe recurrence rate of chronic subdural haematomas is widely reported in the literature and ranges from 3% to 30%.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> Risk factors identified for CSDH recurrence include antiplatelet or anticoagulant drugs,<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> brain atrophy<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> or the radiological features of the haematoma.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> In our study, the overall recurrence rate of CSDH was 26.3%, which is within the range reported in the literature, albeit at the higher end.In this study, the CSDH recurrence rate was lower in the subgaleal drainage group (20.8%) than in the subdural drainage group (31.3%), although this difference was not statistically significant. When comparing these figures with those already published in the literature, we found contradictory results.The studies by Soleman et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> and Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> report the same finding as us, that is a non-statistically significant lower recurrence rate with the use of subgaleal drainage. Other studies, including the meta-analysis by Pranata et al.,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> found subgaleal drainage to have fewer recurrences than subdural drain placement, but their difference was statistically significant.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>However, other studies, such by Häni et al.,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Glancz et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> and Chih et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> recorded a higher recurrence rate in subgaleal drain placement, although these differences were not statistically significant.ComplicationsThe rate of complications after CSDH evacuation in the literature ranges from 6% to 32%.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> The most common complications following CSDH surgery and drain placement are seizures, intracranial haemorrhage and infection.<a class="elsevierStyleCrossRefs" href="#bib0140">28,29</a> In our study, the overall complication rate was 6.6%, which is at the low end of the range reported in the literature.Our study found a higher percentage of complications in the subdural drainage patient group, although this difference was not statistically significant. These results are in line with the majority of studies reviewed, which report subgaleal drainage and subdural drainage to have similar complication rates, such as the studies by Glancz et al.,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Gazzeri et al.,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Zhang et al.,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Häni et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and the meta-analysis by Pranata et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Limitations and strengths of the studyThe main limitation of the study is the low number of patients, given that only 152 patients were analysed, as well as the limitations inherent to retrospective studies. Another limitation is that the type of drainage used in each patient was not randomised, with the choice of drain being at the discretion of the neurosurgeon who performed the procedure. This could have led to the use of the drain thought to be less effective (subgaleal) in those CSDH that appeared less severe on imaging.In contrast, the strengths of the study are the homogeneity of the data and the homogeneity of patient management, as all patients were seen by the same team and in the same centre.ConclusionsWe can therefore attest that:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1The subgaleal drainage complication rate is no higher than for subdural drainage.</li><li class="elsevierStyleListItem" id="lsti0020">2The recurrence rate is lower with subgaleal drainage than with subdural drainage, although this difference is not statistically significant.</li></ul>Subgaleal drainage is a safe and effective alternative to subdural drainage in the treatment of CSDH.Conflicts of interestNone of the authors has any conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2236873" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1872197" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2236872" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1872196" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Hypothesis" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Objectives" ] ] ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "Methodology" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Study population" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Variables" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient management protocol" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical considerations" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistical models" ] ] ] 6 => array:3 [ "identificador" => "sec0055" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Analysis of recurrence" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Analysis of complications" ] ] ] 7 => array:3 [ "identificador" => "sec0070" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Recurrence" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Complications" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Limitations and strengths of the study" ] ] ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-26" "fechaAceptado" => "2024-05-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1872197" "palabras" => array:4 [ 0 => "Chronic subdural hematoma" 1 => "Recurrence" 2 => "Drill" 3 => "Neurosurgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1872196" "palabras" => array:4 [ 0 => "Hematoma subdural crónico" 1 => "Recurrencia" 2 => "Trépano" 3 => "Neurocirugía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectivesChronic subdural hematoma (CSDH) is one of the most common pathologies in our daily practice. The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage, which has shown to decrease its recurrence. However, this procedure can entail risks such as parenchymal damage, infection, or the onset of seizures, prompting the consideration of subgaleal drainage as an alternative.Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH, as well as to analyze the differences in complication rates and recurrence between the two groups. MethodologyA retrospective analytical observational study was conducted, analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022. Patients in whom drainage was not placed were excluded. In all patients, a burr-hole was performed and the type of drainage was chosen by the neurosurgeon. ResultsOut of the 152 patients, subdural drainage was placed in 80 cases (52.63%), while subgaleal drainage was used in 72 cases (47.37%). There were no significant differences in the recurrence rate (30% in the subdural drainage group vs. 20.83% in the subgaleal drainage group; P = .134) or in the complication rate (7.5% in the subdural drainage group vs. 5.5% in the subgaleal drainage group; P = .749). ConclusionsSubgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage, suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivosEl hematoma subdural crónico (HSDc) es una de las patologías más comunes en nuestra práctica diaria. El tratamiento estándar es la evacuación mediante trépano y la colocación de drenaje subdural, el cual ha demostrado disminuir su recurrencia. Sin embargo, este procedimiento puede conllevar riesgos, como el daño al parénquima, la infección o la aparición de crisis comiciales, por lo que el drenaje subgaleal se plantea como una alternativa.Nuestro objetivo es comparar el uso de drenaje subdural y subgaleal en una serie de pacientes con HSDc intervenidos, así como analizar las diferencias tanto en tasa de complicaciones como de recidiva entre ambos grupos. MetodologíaSe realiza un estudio observacional analítico retrospectivo en el que se analizan 152 pacientes con diagnóstico de HSDc intervenidos en nuestro centro desde enero de 2020 hasta abril de 2022. Se excluyeron aquellos pacientes en los que no se colocó drenaje. En todos los pacientes se realizó un trépano y se colocó el tipo de drenaje a elección del neurocirujano. ResultadosDe los 152 pacientes, en 80 se utilizó drenaje subdural (52,63%) y en 72 drenaje subgaleal (47,37%). No hubo diferencias significativas ni en la tasa de recidiva (30%) en el grupo de drenaje subdural vs 20,83%) en el grupo de drenaje subgaleal; P = ,134), ni en la de complicaciones (7,5% en el grupo de drenaje subdural vs 5,5% en el grupo de drenaje subgaleal; P = ,749). ConclusionesEl drenaje subgaleal presenta los mismos resultados clínicos con un índice de recidivas y de complicaciones similar al drenaje subdural, por lo que se plantea como una opción segura y eficaz al drenaje subdural en el tratamiento del HSDc." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1123 "Ancho" => 1650 "Tamanyo" => 73722 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Bar chart of the recurrence analysis." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1078 "Ancho" => 1650 "Tamanyo" => 72057 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Bar chart of the complications analysis." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "TBI: traumatic brain injury." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subdural drainage (n = 80) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subgaleal drainage (n = 72) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years), × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79.1 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.3 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.727<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.620<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (63.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (59.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (36.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (40.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TBI, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (55%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (51.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.745<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Corticosteroids, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (52.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (52.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.0<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thickness (mm), x (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.8 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (6.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.534<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shift (mm), x (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.4 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.2 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.005<a class="elsevierStyleCrossRef" href="#tblfn0015">***</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative thickness (mm), × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.8 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.3 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.519<a class="elsevierStyleCrossRef" href="#tblfn0015">***</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Admission time (days), × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.7 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1 (6.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.715<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time until surgery (h), × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.6 (89.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.9 (101.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.623<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medication, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.248<a class="elsevierStyleCrossRef" href="#tblfn0020">****</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiplatelet agents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (22.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (18.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anticoagulant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.832<a class="elsevierStyleCrossRef" href="#tblfn0020">****</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (23.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (30.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gait instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (26.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limb weakness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (22.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (22.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduced level of consciousness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (5.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dysphasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (8.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (5.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Markwalder grading scale, x (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 (0.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 (0.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.309<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GCS, × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.2 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.3 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.800<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GOS, × (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.490<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.0<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Burr-hole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 (86.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 (87.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Twist drill \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (13.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3645914.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Mann-Whitney test." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "Fisher's exact test." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "***" "nota" => "Student's t-test." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "****" "nota" => "Chi-square test." ] ] ] "descripcion" => array:1 [ "en" => "Descriptive data for all variables." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "UTI: urinary tract infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1.97%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clostridium diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serratia bacteraemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">UTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Empyema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lower gastrointestinal bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute subdural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3645913.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Description of complications." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic subdural hematoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W. 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"fecha" => "2011" "volumen" => "114" "paginaInicial" => "72" "paginaFinal" => "76" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20868215" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of subgaleal and subdural closed drainage system in surgical treatment of chronic subdural hematoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Oral" ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "North Clin Istanb." "fecha" => "2015" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://www.journalagent.com/nci/pdfs/NCI-06977-RESEARCH_ARTICLE-ORAL.pdf" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic subdural haematoma: time to rationalize treatment?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Santarius" 1 => "P.J. Hutchinson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/02688690400004845" "Revista" => array:6 [ "tituloSerie" => "Br J Neurosurg." 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"fecha" => "2015" "volumen" => "123" "paginaInicial" => "1209" "paginaFinal" => "1215" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25794342" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Sjåvik" 1 => "J. Bartek" 2 => "L.M. Sagberg" 3 => "M.L. Henriksen" 4 => "S. Gulati" 5 => "F.L. Ståhl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2016.12.JNS161713" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg." 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Clinical Research

Comparison between the use of subdural and subgaleal drainage in treatment of chronic subdural hematoma

Comparación entre el uso de drenaje subdural y subgaleal en tratamiento del hematoma subdural crónico

Noelia Mirón Jiménez

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noeliamiron96@gmail.com

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, María Ángeles García Pallero, Cristian Leonardo Ortiz Alonso, Celia González Moldes, Cristina Ferreras García, Belén Álvarez Fernández

Servicio Neurocirugía, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain

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CSDH evacuation is expected to become the most commonly performed surgical intervention in neurosurgery departments in the USA in 2030&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Surgical evacuation of CSDH is the standard treatment&#46; Evacuation can be performed in several ways&#58; by craniotomy&#44; standard burr hole or mini-burr hole with twist drill&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> In addition&#44; placement of a subdural drain following burr hole drilling has been shown to decrease the recurrence rate of CSDH&#46; However&#44; this procedure carries risks such as damage to the brain parenchyma&#44; infection and seizures&#46; For this reason&#44; subgaleal drainage is proposed as an alternative&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Hypothesis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The placement of a subgaleal drain in the treatment of CSDH could be an alternative to subdural drainage&#44; 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the medical records of patients with this diagnosis were reviewed and a series of variables were collected which are detailed below&#46; Patients were subsequently assigned to one of two groups&#44; depending on whether they were treated with subgaleal drainage or subdural drainage&#44; in order to identify any differences between the two&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study population</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study included patients over 18 years of age with a diagnosis of CSDH whose haematoma was surgically evacuated using the burr hole or mini-burr hole approach&#44; and in whom either a subgaleal or subdural drain was placed&#46; The placement of a either a subgaleal or subdural drain was at the discretion of the neurosurgeon performing the operation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The exclusion criteria were CSDH which were not treated surgically or which&#44; despite being evacuated&#44; were not drained&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Variables</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 20 variables were collected including age&#44; gender&#44; history of traumatic brain injury&#44; history of taking antiplatelet or anticoagulant medication&#44; use of corticosteroids as part of medical treatment&#44; Markwalder grading scale&#44; haematoma thickness on admission and postoperative CT scan&#44; midline shift&#44; symptoms on admission&#44; Glasgow coma scale on admission and discharge&#44; number of days of admission&#44; time in hours from diagnosis to surgery&#44; type of surgery&#44; type of drainage used&#44; CSDH recurrence or not&#44; type of treatment after recurrence&#44; time to recurrence and post-surgical complications&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Recurrence was defined as symptoms related to the same haematoma and requiring readmission at least four weeks after the first surgical intervention&#46; All complications attributable to surgery&#44; such as surgical site infection&#44; haemorrhage and seizures&#44; were included&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patient management protocol</span><p id="par0070" class="elsevierStylePara elsevierViewall">All patients included in the study followed the same protocol used in our centre for patients undergoing CSDH surgery&#44; which includes antibiotic prophylaxis with cefazolin 2&#8239;g&#47;every 8&#8239;h &#40;or vancomycin 2&#8239;g&#47;every 12&#8239;h in case of allergy to beta-lactam antibiotics&#41; for the duration of the drain being in situ&#46; Subdural drainage is maintained for 24&#8239;h without vacuum and subgaleal drainage is maintained for 48&#8239;h&#44; with vacuum&#44; regardless of the output obtained&#46; In addition&#44; all patients undergo a postoperative brain CT scan prior to discharge 24&#8722;72&#8239;h after surgery&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical considerations</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study was approved by the University Central Hospital of Asturias Independent Ethics Committee&#44; and the guidelines of the Declaration of Helsinki were followed&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical models</span><p id="par0080" class="elsevierStylePara elsevierViewall">Data were analysed using IBM&#174; SPSS&#174; Statistics version 25&#46; After checking the normality of the quantitative variables using the Kolmogorov-Smirnov test&#44; statistically significant differences were looked for in the distribution of the different variables according to the type of drainage the patients received&#46; The Student&#39;s <span class="elsevierStyleItalic">t</span>-test and Mann-Whitney test were used for quantitative variables and the Chi-square test and Fisher&#39;s exact test for qualitative variables&#46; Statistical significance was established at a <span class="elsevierStyleItalic">P</span>-value &#60;&#46;05&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 152 patients were analysed&#44; of which 80 had a subdural drain and 72 a subgaleal drain&#46; The mean age of the sample was 78&#46;7 years &#40;SD&#58; 10&#46;5&#41;&#44; 61&#46;8&#37; of the patients were male&#44; 53&#46;3&#37; had a history of previous traumatic brain injury &#40;TBI&#41; and 52&#46;6&#37; received corticosteroid therapy&#46; In terms of haematoma characteristics&#44; the mean haematoma thickness was 22&#46;4&#8239;mm &#40;SD&#58; 6&#46;8&#41; and the mean midline shift was 8&#46;4&#8239;mm &#40;SD&#58; 4&#46;7&#41;&#46; The mean length of hospital stay was 9&#46;4 days &#40;SD&#58; 6&#46;7&#41; and the mean time to surgery was 68&#46;8&#8239;h &#40;SD&#58; 94&#46;9&#41;&#46; Some 30&#46;9&#37; of patients were on anticoagulants&#44; while 20&#46;4&#37; of patients were on antiplatelet agents&#46; The most common symptom was headache&#44; reported in 27&#37; of patients&#44; followed by gait instability in 25&#46;7&#37; and limb weakness in 22&#46;4&#37;&#46; Some 58&#46;6&#37; of patients had a Markwalder grading scale score of 1 and 60&#46;5&#37; of patients had a Glasgow Coma Scale score of 15 points&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Patients were assigned to one of two groups&#44; depending on whether they were treated with subgaleal drainage or subdural drainage&#44; and the two groups were compared for homogeneity&#46; First&#44; a descriptive analysis of the demographic and clinical variables that could act as confounding factors was performed&#46; The only variable for which statistically significant differences were found was midline shift &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;005&#41;&#44; with a value of 9&#46;4&#8239;mm recorded for subdural drainage patients compared to 7&#46;2&#8239;mm for subgaleal drainage patients&#46; For this reason&#44; a multivariate analysis of midline shift was performed&#44; ruling out that it acted as a confounding factor for both the recurrence analysis &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;252&#41; and the development of complications &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;889&#41;&#46; For the remaining variables&#44; no statistically significant differences were found between the two groups&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The distribution of variables and the comparison between patients given subdural and subgaleal drainage are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Analysis of recurrence</span><p id="par0100" class="elsevierStylePara elsevierViewall">In the group of patients given subdural drainage&#44; 24 had a recurrence&#44; accounting for 30&#37; of the total&#46; In the group of patients given subgaleal drainage&#44; 15 had a recurrence&#44; accounting for 20&#46;83&#37; of the total&#46; These results were analysed using Fisher&#39;s exact test&#44; with no statistically significant differences &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;134&#41;&#46; A summary of the data can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In addition&#44; the odds ratio was calculated for these two variables&#44; obtaining a result of 0&#46;58 with a 95&#37; confidence interval &#40;0&#46;28&#8211;1&#46;21&#41;&#44; which therefore also failed to reach statistical significance&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 39 patients who had a recurrence&#44; 82&#46;1&#37; &#40;32 patients&#41; underwent further surgery&#44; compared to 17&#46;9&#37; &#40;7 patients&#41; in whom a conservative treatment approach was followed&#46; In the subgroup of patients who suffered recurrence&#44; we also analysed the type of treatment they received after recurrence &#40;surgical vs conservative&#41; and the type of drain placed in the initial surgery using Fisher&#39;s exact test&#44; without finding significant differences &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;444&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The mean time to recurrence for all patients was 6&#46;7 weeks &#40;SD&#58; 4&#46;4&#41;&#44; with no significant differences in this variable between the two subgroups according to the type of drainage &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;467&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Analysis of complications</span><p id="par0120" class="elsevierStylePara elsevierViewall">Complications occurred in six patients in the subdural drainage group&#44; 7&#46;5&#37; of the total&#46; In the subgaleal drainage group&#44; complications occurred in four patients&#44; accounting for 5&#46;5&#37; of the total&#46; The results were analysed with Fisher&#39;s exact test and no statistically significant differences were found &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;749&#41;&#46; A summary of the data can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">In addition&#44; the odds ratio was calculated for these two variables&#44; yielding a result of 0&#46;73 with a 95&#37; confidence interval &#40;0&#46;20&#8211;2&#46;68&#41;&#44; which therefore also failed to reach statistical significance&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Of the total number of complications&#44; only two &#40;1&#46;3&#37;&#41;&#44; were directly related to the procedure&#46; The rest were systemic infections&#44; urological infections&#44; lower gastrointestinal bleeding or death due to causes other than CSDH&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> details the number and type of complications in the cohort&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Although surgical evacuation is the established gold standard for the treatment of CSDH&#44; there is less clarity on the surgical technique to be used&#44; as several ways of evacuating this type of haematoma have been described&#44; from large craniotomies to endoscopic techniques&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with or without the addition of various types of drain&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The trend in recent years has been towards increasingly less invasive treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">This study analysed the use of subdural versus subgaleal drainage&#44; regardless of the type of surgery performed to evacuate the haematoma&#44; without finding statistically significant differences either in recurrence or in the development of complications&#46;</p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Recurrence</span><p id="par0145" class="elsevierStylePara elsevierViewall">The recurrence rate of chronic subdural haematomas is widely reported in the literature and ranges from 3&#37; to 30&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Risk factors identified for CSDH recurrence include antiplatelet or anticoagulant drugs&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> brain atrophy<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> or the radiological features of the haematoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> In our study&#44; the overall recurrence rate of CSDH was 26&#46;3&#37;&#44; which is within the range reported in the literature&#44; albeit at the higher end&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In this study&#44; the CSDH recurrence rate was lower in the subgaleal drainage group &#40;20&#46;8&#37;&#41; than in the subdural drainage group &#40;31&#46;3&#37;&#41;&#44; although this difference was not statistically significant&#46; When comparing these figures with those already published in the literature&#44; we found contradictory results&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The studies by Soleman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> report the same finding as us&#44; that is a non-statistically significant lower recurrence rate with the use of subgaleal drainage&#46; Other studies&#44; including the meta-analysis by Pranata et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> found subgaleal drainage to have fewer recurrences than subdural drain placement&#44; but their difference was statistically significant&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">However&#44; other studies&#44; such by H&#228;ni et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Glancz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and Chih et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> recorded a higher recurrence rate in subgaleal drain placement&#44; although these differences were not statistically significant&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Complications</span><p id="par0165" class="elsevierStylePara elsevierViewall">The rate of complications after CSDH evacuation in the literature ranges from 6&#37; to 32&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> The most common complications following CSDH surgery and drain placement are seizures&#44; intracranial haemorrhage and infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> In our study&#44; the overall complication rate was 6&#46;6&#37;&#44; which is at the low end of the range reported in the literature&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Our study found a higher percentage of complications in the subdural drainage patient group&#44; although this difference was not statistically significant&#46; These results are in line with the majority of studies reviewed&#44; which report subgaleal drainage and subdural drainage to have similar complication rates&#44; such as the studies by Glancz et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Gazzeri et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Zhang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> H&#228;ni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the meta-analysis by Pranata et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limitations and strengths of the study</span><p id="par0175" class="elsevierStylePara elsevierViewall">The main limitation of the study is the low number of patients&#44; given that only 152 patients were analysed&#44; as well as the limitations inherent to retrospective studies&#46; Another limitation is that the type of drainage used in each patient was not randomised&#44; with the choice of drain being at the discretion of the neurosurgeon who performed the procedure&#46; This could have led to the use of the drain thought to be less effective &#40;subgaleal&#41; in those CSDH that appeared less severe on imaging&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In contrast&#44; the strengths of the study are the homogeneity of the data and the homogeneity of patient management&#44; as all patients were seen by the same team and in the same centre&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">We can therefore attest that&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1</span><p id="par0190" class="elsevierStylePara elsevierViewall">The subgaleal drainage complication rate is no higher than for subdural drainage&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2</span><p id="par0195" class="elsevierStylePara elsevierViewall">The recurrence rate is lower with subgaleal drainage than with subdural drainage&#44; although this difference is not statistically significant&#46;</p></li></ul></p><p id="par0200" class="elsevierStylePara elsevierViewall">Subgaleal drainage is a safe and effective alternative to subdural drainage in the treatment of CSDH&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">None of the authors has any conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Chronic subdural hematoma &#40;CSDH&#41; is one of the most common pathologies in our daily practice&#46; The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage&#44; which has shown to decrease its recurrence&#46; However&#44; this procedure can entail risks such as parenchymal damage&#44; infection&#44; or the onset of seizures&#44; prompting the consideration of subgaleal drainage as an alternative&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH&#44; as well as to analyze the differences in complication rates and recurrence between the two groups&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A retrospective analytical observational study was conducted&#44; analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022&#46; Patients in whom drainage was not placed were excluded&#46; In all patients&#44; a burr-hole was performed and the type of drainage was chosen by the neurosurgeon&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Out of the 152 patients&#44; subdural drainage was placed in 80 cases &#40;52&#46;63&#37;&#41;&#44; while subgaleal drainage was used in 72 cases &#40;47&#46;37&#37;&#41;&#46; There were no significant differences in the recurrence rate &#40;30&#37; in the subdural drainage group vs&#46; 20&#46;83&#37; in the subgaleal drainage group&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;134&#41; or in the complication rate &#40;7&#46;5&#37; in the subdural drainage group vs&#46; 5&#46;5&#37; in the subgaleal drainage group&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;749&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Subgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage&#44; suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El hematoma subdural cr&#243;nico &#40;HSDc&#41; es una de las patolog&#237;as m&#225;s comunes en nuestra pr&#225;ctica diaria&#46; El tratamiento est&#225;ndar es la evacuaci&#243;n mediante tr&#233;pano y la colocaci&#243;n de drenaje subdural&#44; el cual ha demostrado disminuir su recurrencia&#46; Sin embargo&#44; este procedimiento puede conllevar riesgos&#44; como el da&#241;o al par&#233;nquima&#44; la infecci&#243;n o la aparici&#243;n de crisis comiciales&#44; por lo que el drenaje subgaleal se plantea como una alternativa&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo es comparar el uso de drenaje subdural y subgaleal en una serie de pacientes con HSDc intervenidos&#44; as&#237; como analizar las diferencias tanto en tasa de complicaciones como de recidiva entre ambos grupos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Metodolog&#237;a</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se realiza un estudio observacional anal&#237;tico retrospectivo en el que se analizan 152 pacientes con diagn&#243;stico de HSDc intervenidos en nuestro centro desde enero de 2020 hasta abril de 2022&#46; Se excluyeron aquellos pacientes en los que no se coloc&#243; drenaje&#46; En todos los pacientes se realiz&#243; un tr&#233;pano y se coloc&#243; el tipo de drenaje a elecci&#243;n del neurocirujano&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De los 152 pacientes&#44; en 80 se utiliz&#243; drenaje subdural &#40;52&#44;63&#37;&#41; y en 72 drenaje subgaleal &#40;47&#44;37&#37;&#41;&#46; No hubo diferencias significativas ni en la tasa de recidiva &#40;30&#37;&#41; en el grupo de drenaje subdural vs 20&#44;83&#37;&#41; en el grupo de drenaje subgaleal&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#44;134&#41;&#44; ni en la de complicaciones &#40;7&#44;5&#37; en el grupo de drenaje subdural vs 5&#44;5&#37; en el grupo de drenaje subgaleal&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#44;749&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El drenaje subgaleal presenta los mismos resultados cl&#237;nicos con un &#237;ndice de recidivas y de complicaciones similar al drenaje subdural&#44; por lo que se plantea como una opci&#243;n segura y eficaz al drenaje subdural en el tratamiento del HSDc&#46;</p></span>"
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                  \t\t\t\t">13&#46;3 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;519<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;623<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Medication&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;248<a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antiplatelet agents&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anticoagulant&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;37&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Symptoms&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;832<a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asymptomatic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;2&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Headache&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;23&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22 &#40;30&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gait instability&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;26&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Limb weakness&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18 &#40;22&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;22&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reduced level of consciousness&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;7&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;5&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dysphasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;7&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;8&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;7&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;5&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Markwalder grading scale&#44; x &#40;s&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;3 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;2 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;309<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GCS&#44; &#215; &#40;s&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&#46;2 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&#46;3 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;800<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">GOS&#44; &#215; &#40;s&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;8 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;9 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#46;490<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of surgery&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;0<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Burr-hole&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;86&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">63 &#40;87&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Twist drill&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                          "autores" => array:4 [
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Información del artículo

ISSN: 25298496
Idioma original: Inglés

DOI:10.1016/j.neucie.2024.07.002

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