Network meta-analysis of drain placement for chronic subdural hematoma recurrence and mortality
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Key Takeaway
Consider that subgaleal active drainage may reduce recurrence and subdural irrigation drainage may reduce mortality in chronic subdural hematoma, based on observational network meta-analysis.
This is a systematic review and network meta-analysis of 14 articles comprising 4,161 patients with chronic subdural hematoma undergoing burr-hole drainage. The review compared drain placement in three anatomical locations: subdural drain, subperiosteal drain, and subgaleal drain, with classifications based on location and technique, versus no drain.
The authors synthesized that subgaleal drain was associated with a significantly lower recurrence rate versus no drain (risk ratio 0.43, 95% credible interval 0.20 to 0.96). For Classification II, subgaleal active drainage was associated with reduced recurrence (risk ratio 0.26, 95% credible interval 0.10 to 0.75). For mortality, subgaleal drain had a SUCRA of 72.64%, and subdural irrigation drainage showed the best efficacy with a SUCRA of 63.85%.
The authors note limitations including the need for careful assessment in old and high-risk populations and the requirement for further studies to clarify actual efficacy. Safety data were not reported.
Practice relevance is restrained; the review suggests subgaleal active drainage and subdural irrigation drainage may have potential for reducing recurrence and mortality, respectively, but evidence is from observational studies.
View Original Abstract ↓
BackgroundChronic subdural hematoma (CSDH) is one of the most prevalent diseases encountered in neurosurgery. At present, burr-hole hematoma drainage has been established as the standard surgical intervention for CSDH, effectively reducing the risk of postoperative recurrence. The current study employed systematic review and network meta-analysis (NMA) to assess the impact of drain placement in three different anatomical locations—subdural drain (SDD), subperiosteal drain (SPD), and subgaleal drain (SGD)—on treatment outcomes.MethodsA search was conducted across PubMed, Embase, Cochrane Library, and Web of Science up to February 14, 2026. The Newcastle–Ottawa Scale was used to assess the risk of bias. R (v4.4.0) and Stata18 were used for the NMA.ResultsThis NMA included 14 articles comprising 4,161 patients. The drainage locations evaluated were SDD, SPD, and SGD. Pooled results were analyzed based on two classification systems: Classification I (anatomical location) and Classification II (anatomical location + technique). (1) Recurrence rate: Classification I: According to the league table, SGD was associated with a significantly lower recurrence rate versus No_drain [risk ratio (RR) = 0.43, 95% credible interval (CrI): 0.20–0.96]. Based on the surface under the cumulative ranking curve (SUCRA), SGD (78.25%) ranked as the best intervention. Classification II: According to the league table, subgaleal active drainage (SGD_a) was significantly associated with recurrence versus No_drain (RR = 0.26, 95% CrI: 0.10–0.75), and also ranked highest in SUCRA (79.83%). (2) Mortality: Classification I: SGD was associated with reduced mortality (SUCRA = 72.64%). Classification II: subdural irrigation drainage (SDD_irr) showed the best efficacy in reducing mortality (SUCRA = 63.85%).ConclusionSGD_a and SDD_irr exhibit significant potential in reducing recurrence rates and mortality, respectively, in the management of CSDH. However, due to the physiological conditions and disease features of old and high-risk populations, careful assessment is necessary when selecting treatment approaches in clinical practice. Further studies should be conducted to clarify the actual efficacy of these two treatment modalities.Systematic review registrationThis study is a systematic review and network meta-analysis and has been registered in the PROSPERO database. Registration ID: CRD42024587692. Official URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=587692.
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