Burr hole craniotomy for chronic subdural hematoma under local anesthesia may reduce risks of postoperative delirium compared to general anesthesia

1. In patients with chronic subdural hematoma (cSDH) requiring burr hole craniotomy, operation under local anesthesia (LA) was safe, well-tolerated, and associated with significantly reduced risks of postoperative delirium compared to general anesthesia (GA). 

Evidence Rating Level: 1 (Excellent)

cSDH is projected to become the most common cranial neurosurgical condition by 2030. Present standard management is burr hole craniotomy. However, the procedure is generally performed under GA while the elderly, the population most at risk for cSDH, is vulnerable to complications associated with GA such as postoperative delirium. Burr hole craniotomy under LA has been performed, although there is a significant knowledge gap surrounding its safety and efficacy. This parallel-group, single-center, open-label, prospective randomized clinical trial included adults aged 18 years or older who had a confirmed diagnosis of cSDH, and required hematoma evacuation. 50 patients were randomized to undergo surgery under GA (propofol and remifentanil; n = 25; mean [SD] age, 77.3 [10.4] years; 20% female) or LA (bupivacaine and lidocaine; n = 25; mean [SD] age, 78.1 [9.3] years; 28% female). LA was associated with a significantly lower rate of postoperative delirium (4% vs 32%, OR 0.09; 95%CI, 0.01-0.79; p=0.03; NNT=4) and significantly lower procedural times (139.3±53.0 vs 196.0±52.1 minutes; p=0.002). The overall complication rate was 8% in the LA group and 32% in the GA group (OR 0.18; 95% CI, 0.03-0.96; p = 0.08; NNT = 5). The severity of complications was comparable between groups. Overall, burr hole craniotomy for cSDH under LA is safe, well-tolerated, and leads to significantly lower risks of postoperative delirium compared to GA.

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