Chronic Subdural Hematoma Surgical Technique

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Chronic Subdural Hematoma Surgical Technique

(1) Twist drill craniostomy for chronic subdural hematoma is a relatively safe technique that can be employed under local anesthesia and thus can be considered as first-line treatment in high-risk surgical candidates. (2) Single and double burr hole craniotomies have shown comparable results. (3) Intraoperative irrigation during burr-hole craniostomy doesn’t affect the outcome. (4) Drain insertion after hematoma evacuation lowers the recurrence risk. (5) Position of the drain is not significant but early drain removal is associated with higher recurrence rates. (6) Craniotomy is associated with high morbidity and mortality, hence should be reserved for recurrent and large septate hematoma cases. (7) Head elevation in the postoperative period reduces recurrence. (8) Embolization of the middle meningeal artery (EMMA): A novel treatment modality, is promising but requires further approval in terms of large sample-sized multicenter randomized control trials. In conclusion, further research is required on the subject to formulate guidelines regarding the management of this common neurosurgical emergency 1)

Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates.

The most usual procedures for chronic subdural hematoma treatment include single or multiple burr hole drainage craniectomy. There is still controversy, however, about the risks and benefits of the different surgical approaches and types of drainage.

Till 1970s, craniotomy was the most commonly used method. Burr hole trephination for chronic subdural hematoma became the most preferred method from 1980s. In 1977, Twist drill craniostomy for chronic subdural hematoma was introduced. Closed system drainage after a Burr hole (BH) or a Twist drill (TD) became the most frequently used surgical method 2).

Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders 3).

The duration of procedure was significantly more in Burr-Hole Craniostomy BHC than in Twist-Drill Craniostomy TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH 4)

Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For chronic subdural hematoma recurrences, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space 5).

Chronic subdural hematoma treatment in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits.

Chronic subdural hematoma are ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care.

Originally, CSDHs were treated by open craniotomy 6) 7) 8) 9). Later burr hole trephination (BHT) was adopted because it was less invasive with lower morbidity and recurrence rates when compared with standard craniotomy 10) 11) 12) 13) 14) 15).

The traditional methods include evacuation via a burr hole with closed system drainage with or without irrigation, two burr-hole craniostomy with closed system drainage with irrigation or craniotomy, with subdural drain or without drain placement.

Minicraniotomy (MC) emerged as an attractive alternative to BHT as it allows better visualisation of the subdural cavity, enabling better haemostasis and resection of membranes.

Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier anticoagulation resumption treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates 16).

Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial) 17).

Burr hole trephination for chronic subdural hematoma

see Burr hole trephination for chronic subdural hematoma.

Twist drill craniotomy for chronic subdural hematoma

see Twist drill craniostomy for chronic subdural hematoma.

Subdural drain for chronic subdural hematoma

see Subdural drain for chronic subdural hematoma.

Subdural evacuating port system for chronic subdural hematoma

see Subdural evacuating port system for chronic subdural hematoma.

Subperiosteal drain for chronic subdural hematoma

see Subperiosteal drain for chronic subdural hematoma

Craniotomy for chronic subdural hematoma

see Craniotomy for chronic subdural hematoma.

Neuroendoscopy

see Chronic subdural hematoma neuroendoscopy.

References

1)

Siddique AN, Khan SA, Khan AA, Aurangzeb A. Surgical Treatment Options For Chronic Subdural Haematoma. J Ayub Med Coll Abbottabad. 2022 Jul-Sep;34(3):550-556. doi: 10.55519/JAMC-03-10225. PMID: 36377174.
2) , 5)

Lee KS. How to Treat Chronic Subdural Hematoma? Past and Now. J Korean Neurosurg Soc. 2019 Mar;62(2):144-152. doi: 10.3340/jkns.2018.0156. Epub 2018 Nov 30. PubMed PMID: 30486622; PubMed Central PMCID: PMC6411568.
3)

Certo F, Maione M, Altieri R, Garozzo M, Toccaceli G, Peschillo S, Barbagallo GMV. Pros and cons of a minimally invasive percutaneous subdural drainage system for evacuation of chronic subdural hematoma under local anesthesia. Clin Neurol Neurosurg. 2019 Oct 10;187:105559. doi: 10.1016/j.clineuro.2019.105559. [Epub ahead of print] PubMed PMID: 31639631.
4)

Thavara BD, Kidangan GS, Rajagopalawarrier B. Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma. Asian J Neurosurg. 2019 Apr-Jun;14(2):513-521. doi: 10.4103/ajns.AJNS_37_19. PubMed PMID: 31143272; PubMed Central PMCID: PMC6516027.
6)

Ernestus R, Beldzinski P, Lanfermann H, Klug N. Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 1997;48:220–5.
7)

McKissock W, Richardson A, Bloom WH. Subdural hematoma: a review of 389 cases. Lancet 1960;1:1365–9.
8)

Tyson G et al. The role of craniectomy in the treatment of chronic subdural hematomas. J Neurosurg 1980;52:776–81.
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Putnam IJ, Cushing H. Chronic subdural hematoma. Its pathology, its relation to pachymeningitis hemorrhagica, and its surgical treatment. Arch Surg 1925;11:329–93.
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Chronic Almenawer S et al. Subdural hematoma management: a systematic review and meta-analysis of 34829 patients. Ann Surg 2014;259(3):449–57.
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Lee J, Ebel H, Ernestus R, Klug N. Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol 2004;61:523–5528.
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Ducruet A et al. The surgical management of chronic subdural hematoma. Neurosurg Rev 2012;35:155–69.
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Leroy H et al. Predictors of functional outcomes and recurrence of chronic subdural. J Clin Neurosci 2015;22:1895–900.
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Regan J, Worley E, Shelburne C, Pullarkat R, Burr Watson J. Hole Washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis. PLoS One 2015;10(1):1–8.
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Mondorf Y, Abu-Owaimer M, Gaab M, Oertel J. Chronic subdural hematoma – Craniotomy versus burr hole trephination. Br J Neurosurg 2009;23(6):612–6.
16)

Garber S, McCaffrey J, Quigley EP, MacDonald JD. Bedside Treatment of Chronic Subdural Hematoma: Using Radiographic Characteristics to Revisit the Twist Drill. J Neurol Surg A Cent Eur Neurosurg. 2016 Jan 25. [Epub ahead of print] PubMed PMID: 26807616.
17)

Agrawal A, Pacheco-Hernandez A, Moscote-Salazar LR. Letter: Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial). Neurosurgery. 2019 Aug 6. pii: nyz289. doi: 10.1093/neuros/nyz289. [Epub ahead of print] PubMed PMID: 31387117.

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