Active and Passive Drainage Strategies, Including Closed and Underwater Systems, in Chronic Subdural Hematoma: A Systematic Review Focusing on Drain Type, Position, and Reoperation-Requiring Recurrence: Active and Passive Drainage Strategies, Including Closed and Underwater Systems, in Chronic Subdural Hematoma

Cezmi Cagri Turk; Abdullah Konak

doi:10.5281/zenodo.18059600

Authors

Cezmi Cagri Turk University of Health Sciences https://orcid.org/0000-0003-1497-7827
Abdullah Konak Antalya Education and Research Hospital, Neurosurgery Clinic, Antalya, Turkey

DOI:

https://doi.org/10.5281/zenodo.18059600

Keywords:

Burr-hole, Chronic subdural hematoma, Postoperative drainage, Recurrence, Reoperation

Abstract

Background

Chronic subdural hematoma (CSDH) is a common neurosurgical condition and its incidence continues to increase with aging demographics and widespread antithrombotic use. Although burr-hole evacuation is the standard surgical treatment, postoperative recurrence remains a significant challenge, often requiring repeat surgery. While the use of postoperative drainage is widely accepted, substantial variability exists regarding drain type, position, and drainage strategy.

Objectives

This systematic review aimed to evaluate the impact of different postoperative drainage strategies, including drain position, drainage system design, and active versus passive drainage, on reoperation-requiring recurrence following burr-hole evacuation for chronic subdural hematoma.

Methods

A systematic literature search of PubMed/MEDLINE was conducted using five predefined keyword combinations. Studies were eligible if they included adult patients undergoing burr-hole evacuation with postoperative drainage and reported recurrence requiring reoperation as a primary or clearly defined secondary outcome. Study selection and data extraction were performed according to PRISMA 2020 guidelines.

Results

A total of 146 records were identified, of which 8 comparative studies met the inclusion criteria. Drain positions evaluated included subdural, subperiosteal, and subgaleal placement. Drainage strategies comprised passive and active suction systems, conventional closed drainage, and underwater drainage systems. Extracranial drainage (subperiosteal or subgaleal) demonstrated recurrence rates comparable to subdural drainage, without an increased need for reoperation. Active suction did not consistently reduce reoperation-requiring recurrence compared with passive drainage. Underwater drainage was associated with lower recurrence rates, reduced pneumocephalus, and shorter hospital stay; however, evidence was limited to a single-center retrospective study.

Conclusion

Reoperation-requiring recurrence after burr-hole evacuation for CSDH appears to be influenced more by effective closed drainage and cavity collapse than by drain position alone. Extracranial and passive drainage strategies provide outcomes comparable to traditional approaches, while underwater drainage shows promising results that warrant further prospective validation.

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Active and Passive Drainage Strategies, Including Closed and Underwater Systems, in Chronic Subdural Hematoma: A Systematic Review Focusing on Drain Type, Position, and Reoperation-Requiring Recurrence