Flat panel detector-CT with endovenous injection. Description of a novel technique for obtaining cerebral arteries imaging: Technical note


Romanian Neurosurgery  |  Volume XXXI  |  Number 2 |  2017  |  April-June 

 
Article 

 
 Management of subdural chronic hematoma in 

Colombia: national survey  

Marticela Morales-Cabeza, Amit Agrawal, Gabriel Alcala-Cerra, Huber S. Padilla-Zambrano, Andres M. Rubiano, 

Alfonso Pacheco-Hernandez, Luis Gabriel Moscote-Salazar, Hernando Alvis-Miranda, Luis Rafael  Moscote-Salazar  
COLOMBIA, INDIA, VENEZUELA 

 

 

 

DOI: 10.1515/romneu-2017-0031 
 



 
 
 
 
 

Romanian Neurosurgery (2017) XXXI 2: 197 - 202 | 197 

 

 
 
 
 
 
 

DOI: 10.1515/romneu-2017-0031   

Management of subdural chronic hematoma in Colombia: 
national survey 

Marticela Morales-Cabeza1, Amit Agrawal2, Gabriel Alcala-Cerra3, 
Huber S. Padilla-Zambrano1, Andres M. Rubiano4, Alfonso 
Pacheco-Hernandez5, Luis Gabriel Moscote-Salazar6, Hernando 
Alvis-Miranda1, Luis Rafael  Moscote-Salazar5 
1University of Cartagena, Cartagena de Indias, COLOMBIA 
2Department of Neurosurgery, Narayna Medical College Hospital, Chinthareddypalem, Andhra 
Prades, INDIA 
3E.S.E Hospital Universitario CARI, Barranquilla, COLOMBIA; Department of Neurological 
Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of 
Cartagena, Cartagena de Indias, COLOMBIA 
4Hospital Universitario de Neiva-Fundacion Meditech, Neiva, Universidad El Bosque, Bogota, 
COLOMBIA 
5Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) 
Research Group, University of Cartagena, Cartagena de Indias, COLOMBIA 
6Hospital Universitario de Maracaibo, Universidad del Zulia, Maracaibo, VENEZUELA 

 
Abstract: Chronic subdural hematoma is a growing neurological pathology, especially 
in older people. Thus, describing how this entity is approached in Colombia is of great 
importance because it allows to evaluate and contrast this approach with that of other 
countries, comparing the techniques used, therapeutic management and additional 
measures. In this study, this comparison was carried out using a self-administered survey 
with 16 multiple-choice items. The results were evaluated in Microsoft Excel, 
determining measures of central tendency accompanied by frequencies and percentages. 
As an initial management, 75.5% preferred to use 1Burr Hole and, in cases of recurrence, 
craniotomy is the choice in 50% of cases. Regarding the placement of drainage, its use 
was estimated to be 83.3%, especially the subdural system closed to external drainage, 
with a preference of 85.2%, and without use of corticosteroids as adjuvant therapy in 88.9 
% of respondents. These data are consistent with the results of studies in other countries 
regarding the management of this pathology. 
Key words: Chronic subdural hematoma; Craniotomy, Neurosurgery 

 



 
 
 
 
 
198 | Morales-Cabeza et al - Management of subdural chronic hematoma in Colombia 

 

 
 
 
 
 
 

Introduction 
Chronic subdural hematoma (HSC) is one 

of the most common neurological pathologies 
(1-4), with an incidence of 3.4 per 100,000 
population in patients younger than 65 years 
of age and 8-58 per 100,000 in older adults. 65 
years (5, 6), being more frequent in the male 
sex, (7) people with risks of falls, convulsions, 
alcohol abuse, coagulation disorders (2, 8) and 
associated medicines (9). Its origin begins 
from the formation of acute hematomas, 
which may resolve spontaneously or increase 
in size and continue to enlarge, generating 
rupture of small veins as it expands, further 
increasing the amount of blood and thus 
becoming a HSC8, (10). It is rarely produced 
as a complication of cuts of unbroken cerebral 
aneurysms (11). Its diagnosis is performed by 
imaging, mainly CT scan and magnetic 
resonance imaging (MRI). (12) The treatment 
options include craniotomy, Burr Hole 
craniostomy (BHC), Twist drill craniostomy 
(TDC), endoscopic management and Medical 
management; however, there is still no 
consensus on the technique of choice. (8) 

On the other hand, the use of preventive 
measures to reduce recurrence has been 
implemented, including: Use of 
corticosteroids, angiotensin receptor 
antagonists, correct positioning of the head 
postoperatively, continuous subdural 
irrigation, among others (13). Despite this, 
recurrence rates have been reported from 6.6 
to 38% and mortality rates of 3.8% (8). This 
high recurrence rate, coupled with the 
prevalence of this condition, raises the need to 
know how this pathology is approached in 

Colombia, the conditions that could be 
influencing this method and, at the same time, 
to evaluate the implications that this may have 
on the patient. 

Materials and methods 
A descriptive observational study was 

performed. We included 54 participants who 
were part of the medical staff of some 
Colombian institutions. As the only criterion 
of inclusion, it was necessary that participation 
should be voluntary, after signing an informed 
consent. A survey was carried out using a 
virtual platform (ww.encuestafacil.com), 
which consisted of 16 multiple-choice 
questions related to the management of HSC, 
and had variables such as: academic training 
(place of training in general neurosurgery and 
Profession), use of surgical techniques (Burr 
hole, twist drill, others), use of drugs (steroids, 
anticonvulsants, antibiotics), use of devices 
(drains) and other measures. 

The data were entered in a database in 
Microsoft Excel and analyzed using the same 
program, using descriptive statistics by means 
of determination of measures of central 
tendency, frequency and percentages, 
according to the options marked in the survey. 

Results 
Socio-demographic characteristics 

Of the 54 participants in the study, 92.6% 
(50) were men, with a male: female ratio of 
approximately 13: 1. The countries where 
Neurosurgery was performed were Colombia 
with 43 subjects (79.6%), followed by other 
countries in Central and South America with 8 



 
 
 
 
 

Romanian Neurosurgery (2017) XXXI 2: 197 - 202 | 199 

 

 
 
 
 
 
 

subjects (14.8%), North America with 2 (3.7 
%) And another continent 1 subject (1.9%). As 
for their profession, 77.8% of the respondents 
were general neurosurgeons and 12.2% had 
another sub-specialty. 

Surgical aspects 
As for the initial management of the 

patient, the technique of choice was 1 Burr 
Hole, with a prevalence of 75.5% when 
compared to the others (Figure 1). The 
technique of choice in cases of recurrence was 
also evaluated (Table 1). The irrigation of the 
dural cavity during the surgical procedure and 
the use of drains at the end were reported in 
high proportions, with values of 85.2% and 83 
% respectively. 

 
Figure 1 - Technique of preference in the initial 

management of HSC 
 

TABLE 1 

Technique of choice in the management of 
recurrent HSC 

 Number of 
patients  

 (%) 

Twist Drill 1 1,9 
1 Burr hole 18 33,3 
2 Burr hole 7 13 

Subdural Peritoneal 
Shunt 

1 1,9 

Craniectomy 27 50 
Total  54 100 

 

Use of medicines 
Regarding the management of patients in 

whom there were no seizures, 88.9% of the 
participants did not use anticonvulsants, and 
11.1% used them, administered for less than 1 
day (1.9%) or 7 to 5 days (9.3%). The use of 
antibiotics was also investigated, evidencing a 
significant use of these in a preoperative 
(83.3%) and postoperative (64.8%), with a 
predominance of 82.7% for cephalosporins, 
17% for others Types (except for 
fluoroquinolones and penicillin, of which no 
use was reported by specialists in the 
management of this pathology). Another of 
the drugs evaluated was the use of systemic 
steroids as one of the measures for the 
management of patients with HSC, evidencing 
that 48 (88.9%) of the respondents deny their 
use compared to only 6 (11.1%) That allow you 
to use it. 

Other measures 
The implementation of other additional 

measures for the management of HSC, such as 
the use of the head in zero degrees in the 24 
hours post-surgical were studied, reporting 
that 70.4% of the respondents use this 
measure, compared to 29.6% who refrain from 
using it. The use of drains was also evaluated, 
revealing that 46 of the participants (85.2%) 
prefer a subdural system closed to external 
drainage, 2 (3.7%) prefer a closed subgaleal 
system to external drainage, while 6 of them 
(11.1%) did not use any drains. Regarding the 
perception about the importance of age as a 
determinant of the surgical decision, 77.8% 
considered that it is not a determining 
parameter when deciding to intervene, while 
the other 22.2% consider it important. 



 
 
 
 
 
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Discussion 
The HSC is one of the neurological 

pathologies that is reported more frequently 
(1). Its handling must be in charge of a trained 
professional. In the present study, 77% of the 
participants who perform the approach of 
these patients are general neurosurgeons, 
compared to 22% who have a subspecialty, 
which reflects that due to the high frequency 
of this pathology, the management By a 
general neurosurgeon is more frequent, 
having all the capacities and training to be able 
to offer him of equal way, an adequate 
attention to the patient, without that this has 
negative repercussion in the morbidity and 
mortality. The training country of the majority 
of the participants was Colombia; A fact that 
can be explained by the lack of opportunities 
for specialization abroad, personal preferences 
or socioeconomic issues. Determining the 
cause of this result would require another 
study that is not the subject of this article. 

The variety of surgical techniques to 
intervene to these patients, generates 
controversy about the procedure of choice; 
(Burr-Hole 1, 8 of these (15.1%) 2 Burr-Hole 
and only 5 (9.4%) the craniectomy. These data 
coincide with those observed in countries like 
Nigeria (14) and other studies where the first 
two techniques are of choice (15) mainly due 
to the low rates of recurrence reported (8-
26%). Irrigation of the subdural space in a 
systematic way (2, 14, 16) and that in our 
country is reported in 85.2% of cases. 

Regarding the procedure of choice in cases 
of recurrence, the most used was the 
craniotomy, followed by the 1 Burr Hole, 2 
Burr Hole, and TDC, which contrasts with 

other studies where BHC occupies the first 
place, followed by the TDC, The latter 
considered advantageous because it can be 
performed at the patient's bedside with the use 
of local anesthesia, together with cost and time 
saving (8). This difference could be given by 
the population studied, places of training and 
access to certain materials and procedures. 
Therefore, the technique of choice may vary 
depending on where the intervention is 
performed, without representing malpractice 
or prejudice to the patient. 

The use of antibiotics is one of the main 
measures used in any type of surgery and has 
been shown to be largely used prophylactically 
in the pre- and postoperative phase to treat 
HSC (83.3% and 64, 8% respectively). 
However, there is little information in the 
literature about its use, dosage, duration and 
types of recommended antibiotics. In most 
scenarios where they are used, it is a way of 
intervening for an existing infection (17). 
Within the medication given to the patient, the 
anticonvulsants have been routinely used in 
the post-surgical period, based on the concept 
that after the intervention, patients may 
frequently exhibit some extent of the 
underlying traumatic brain injury, thus 
establishing a risk factor for seizures. (6) 
Although the data indicate that 88.9% do not 
use them, 9.7% use it for 5 to 7 days and 1% use 
it only in the first hours. Despite this, its use is 
not yet considered as a routine or standardized 
practice (14). The role of inflammation as a 
determinant in the pathophysiological process 
of HSC has been known for several years. 
Despite this, the use of steroids as additional 
therapy is limited in many countries (14) 



 
 
 
 
 

Romanian Neurosurgery (2017) XXXI 2: 197 - 202 | 201 

 

 
 
 
 
 
 

including Colombia, due to limited clinical 
evidence of its effectiveness and cost-benefit 
relationship (18, 19). 

In countries like Canada, abstention from 
its use occurs in more than 80% of 
neurosurgeons (18). After surgery, most 
neurosurgeons place a subdural system closed 
to external drainage. It has been shown that its 
use after the evacuation of a HSC can 
accelerate the washing of inflammatory and 
fibrinolytic factors confined within the 
subdural cavity, thus decreasing its recurrence 
(2, 13, 20). In spite of this, the use of subdural 
drainage is not a systematic practice in all 
countries. In the present study, 83.3% place a 
drainage at the end of the surgical procedure, 
and in countries such as Nigeria, The use is 
42.8%, (14) whereas a survey in the United 
Kingdom and the Republic of Ireland showed 
that only 11% of neurosurgeons always place a 
drain (11). 

Concern for surgical risk is one of the main 
Reasons why some neurosurgeons avoid their 
use, due to the fear of: perforation of the 
cortex, generation of a subdural hematoma or 
the formation of a subdural empyema bacterial 
(12). With respect to prognosis and 
conceptions about the intervention, more than 
70% of the participants consider that age is not 
a determining factor when evaluating a 
possible intervention, which indicates that the 
majority of patients who enter and are not 
candidates for Medical treatment, will have the 
opportunity to be managed surgically to seek 
the final resolution of your picture. This 
generates higher cure rates and is consistent 
with other countries (1). 

Despite this, there are reports that young 

patients tend to have a better outcome. (21) 
But despite this controversy, this should not be 
a reason to delay or deny intervention in older 
patients and more so because they are the first 
group affected. 

After the surgical intervention, the 
adoption of measures such as variation in the 
position on the stretcher, have been 
considered as support tools. Although 70.4% 
of the participants use the head in zero 
degrees; In other places, Tredenlenburg 
position is used in order to increase 
cerebrospinal fluid (CSF) pressure and help 
brain reexpansion. Despite this, the results are 
considered contradictory, and the role of the 
positions as stimulants or inhibitors of 
recurrence has not been determined. (14) 

Regarding the limitations of the study, it 
should be clarified that equal proportions of 
respondents from each of the participating 
hospital centers were not taken into account, 
which would make it ideal to carry out another 
study that includes a greater number of 
professionals from other regions of the 
country. Country, to confirm if the results 
obtained are similar or consistent with those of 
the present study. In addition, the fact that the 
majority of participants presented their 
training in this country could have influenced 
the results obtained. 

Conclusion 
Chronic subdural hematoma is a pathology 

that in Colombia is approached mainly by the 
general neurosurgeon, and whose treatment 
agrees with most measures adopted in other 
countries at the intervention level of choice, 
medication use and additional measures. 



 
 
 
 
 
202 | Morales-Cabeza et al - Management of subdural chronic hematoma in Colombia 

 

 
 
 
 
 
 

Correspondence 
Dr. Luis Rafael Moscote-Salazar 
Email: mineurocirujano@aol.com 

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