Subdural Irrigation Critical in Chronic Subdural Hematoma Treatment: Lancet

A recent FINISH trial published in the The Lancet provided new insights into the treatment of chronic subdural hematoma (CSDH) which is a common intracranial emergency requiring surgical intervention. The trial was conducted across five neurosurgical units in Finland and brought into focus the significance of subdural irrigation during burr-hole drainage surgery.

Chronic subdural hematoma is typically treated by drilling a burr hole to access the hematoma which is followed by irrigation of the subdural space and insertion of a subdural drain. While the benefits of using a subdural drain have been well-documented, the therapeutic effect of subdural irrigation was not previously evaluated in a meticulous manner.

From January 2020 to August 2022, the FINISH trial enrolled a total of 589 patients out of 1644 assessed to determine if the addition of irrigation provided a significant advantage. The patients were randomly assigned to undergo burr-hole drainage either with or without subdural irrigation. The primary focus was on the reoperation rate within six months, while secondary outcomes included functional outcomes and mortality rates.

The study found that the reoperation rate was markedly higher in patients who did not receive irrigation. Also, 18.3% of the non-irrigation group required reoperation when compared to 12.6% in the irrigation group by highlighting a difference of 6.0 percentage points. Although the trial set out to establish non-inferiority of the no-irrigation approach, the outcomes did not support this hypothesis. There were no significant differences in functional outcomes or mortality rates between the two groups, indicating that while irrigation may reduce the need for reoperation, it does not affect overall survival or functional recovery.

The detailed findings revealed that severe adverse events, including systemic infections, intracranial hemorrhage and epileptic seizures were reported in both groups at comparable rates. This suggests that while subdural irrigation enhances reoperation rates, it does not increase the risk of serious complications.

The evidence from the FINISH trial strongly supports the continued use of subdural irrigation during burr-hole drainage surgery for chronic subdural hematoma. Given the higher reoperation rate associated with the absence of irrigation, the study underlines the importance of this procedure in improving the surgical outcomes.

With a robust sample size and rigorous methodology, this research ensures that the results are reliable and applicable to a broad patient population. The findings advocate for standardizing subdural irrigation as part of the burr-hole drainage procedure that can potentially lead to better patient outcomes and reduced healthcare costs associated with reoperations.

Source:

Raj, R., Tommiska, P., Koivisto, T., Leinonen, V., Danner, N., Posti, J. P., Laukka, D., Luoto, T., Rauhala, M., Tetri, S., Korhonen, T. K., Satopää, J., Kivisaari, R., Luostarinen, T., Schwartz, C., Czuba, T., Taimela, S., Lönnrot, K., Järvinen, T. L. N., … Zeiler, F. A. (2024). Burr-hole drainage with or without irrigation for chronic subdural haematoma (FINISH): a Finnish, nationwide, parallel-group, multicentre, randomised, controlled, non-inferiority trial. In The Lancet. Elsevier BV. https://doi.org/10.1016/s0140-6736(24)00686-x