Subgaleal drain for chronic subdural hematoma

Subgaleal drain for chronic subdural hematoma

Subgaleal drainage system is relatively less invasive, safe, and technically easy. So it is applicable for aged and higher risk patients 1).

Subgaleal suction drain was found to be an effective and safe method in the study of Yadav et al., for chronic subdural hematoma surgery 2).

It significantly reduced the incidence of recurrence. Similar observations were made in the study of Gazzeri et al. 3)

They placed the tip of suction drain on burr hole which can assist in continuous evacuation of hematoma or collected air.

Yadav et al., placed suction tip away from burr hole site which could avoid accidental slippage of tip in subdural space. Subgaleal drainage could avoid the risk of an acute hemorrhage from neo membrane injury which may occur during introduction and the removal of a subdural drain. It also reduces chances of brain parenchymal injury especially after suction drain 4).

A major complication of intracerebral hemorrhage could be due to a blind placement of the subdural drain.

There is a report of one acute SDH after subgaleal drain 5).

The subgaleal drain reduced the chances of significant pneumocephalus in the study of Yadav et al. 6).

The placement of subgaleal suction catheter could prevent the collection of subdural air, thus minimizing the risk of recurrence 7).

Postoperative infection in the subgaleal space has also been reported after subgaleal drainage 8).

A total of 763 patients with surgically evacuated unilateral CSDH were included for analysis. The recurrence rate was 14% while 12% of patients died during follow-up (1 year). In a association model, hematoma size, drain type, drainage time, presence of complications, and Glasgow Coma Score were significantly associated to recurrence. Subdural drain was associated with a lower recurrence risk than subgaleal drain. The preoperative model included hematoma size, hematoma density, and history of hypertension. The postoperative model included further drain type, drainage time, and surgical complications.

The nomograms allow easy assessment of the recurrence risk for the individual patient, providing a better possibility for individual adjustment of treatment and follow-up. The predictive performance indicates that significant unaccounted or unknown factors still remain. The association test found passive subdural drain superior to passive subgaleal drain in minimizing the risk of CSDH recurrence 9).



Oral S, Borklu RE, Kucuk A, Ulutabanca H, Selcuklu A. Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma. North Clin Istanb. 2015 Sep 26;2(2):115-121. doi: 10.14744/nci.2015.06977. eCollection 2015. PubMed PMID: 28058351; PubMed Central PMCID: PMC5175088.
2) , 6)

Yadav YR, Parihar V, Chourasia ID, Bajaj J, Namdev H. The role of subgaleal suction drain placement in chronic subdural hematoma evacuation. Asian J Neurosurg. 2016 Jul-Sep;11(3):214-8. doi: 10.4103/1793-5482.145096. PubMed PMID: 27366247; PubMed Central PMCID: PMC4849289.
3) , 5) , 7) , 8)

Gazzeri R, Galarza M, Neroni M, Canova A, Refice GM, Esposito S. Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma. Acta Neurochir (Wien). 2007;149(5):487-93; discussion 493. Epub 2007 Mar 28. PubMed PMID: 17387427.

Choudhury AR. Avoidable factors that contribute to complications in the surgical treatment of chronic subdural haematoma. Acta Neurochir (Wien). 1994;129(1-2):15-9. PubMed PMID: 7998490.

Andersen-Ranberg NC, Debrabant B, Poulsen FR, Bergholt B, Hundsholt T, Fugleholm K. The Danish chronic subdural hematoma study-predicting recurrence of chronic subdural hematoma. Acta Neurochir (Wien). 2019 May;161(5):885-894. doi: 10.1007/s00701-019-03858-9. Epub 2019 Mar 26. PubMed PMID: 30915574.

Burr hole trephination for chronic subdural hematoma

Burr hole trephination for chronic subdural hematoma

Burr hole trephination for chronic subdural hematoma with a closed drainage system

Double burr hole trepanation combined with a subperiostal passive closed-drainage system is a technically easy, highly effective, safe, and cost-efficient treatment strategy for symptomatic chronic subdural hematomas. The absence of a drain in direct contact with the hematoma capsule may moderate the risk of postoperative seizure and limit the secondary spread of infection to intracranial compartments 1).

The main aim of surgery should be a complete removal of the aggressive liquid. In case of many membranes that separate the hematoma into chambers like honeycomb an open procedure cannot be avoided. Nevertheless, the preferred operative therapy for most of CSDH is a burr hole craniostomy with a closed drainage system 2) 3).

Surgical Technique

Surgical safety checklist

Preoperative antibiotic prophylaxis

Skin Preparation


Preferably under general anesthesia the surgical approach should be over the thickest part of the hematoma and the patients positioned in a way that the burr hole comes to the highest point to avoid pneumocephalus.

Therefore, the head is rotated and the ipsilateral shoulder is usually padded.

The supine position is used with the patient‘s head rotated for temporal access. Extremes of head rotation can obstruct the jugular venous drainage, and a shoulder roll can combat this problem or lateral positioning (park bench position).

Skin incision

Sites of predilection are frontal about 1 cm anterior to the coronal suture or parietal posterior to the parietal eminence. The area around Kocher’s point offers a safe entry without injury of branches of the middle meningeal artery or the motor strip. Additionally, the skin incision should be brought, if possible, into alignment with an eventual future skin flap for craniotomy. A curved flap avoids a burr hole position directly under the skin cut and a possible impaired wound-healing as a consequence. Further, the base of the C-shaped incision should be opposite of the planned direction of the drain tip. Obviously, a kinking of the drain is obviated 4).

Burr Holes

A performed burr hole with a diameter of 14 mm enables a sufficient angulation of the drain tip and allows an insertion of the drainage close to the calvaria.

Dura mater opening

The dura mater is coagulated and cut in a stellate fashion.

Technical issues

Under direct vision, the external membrane is perforated by the tips of the bipolar forceps. In general, there are the open or the closed ways of evacuation of the hematoma after the drain is inserted 5)

The open variant should be chosen only if irrigation is desired: the dura and external membrane are opened widely so that the fluid of the hematoma and irrigation can drip out beside the drain during rinsing. Removal of the fluid enriched with inflammatory mediators is considered obviously as an advantage, although a remaining pneumocephalus is seen as an approved factor of recurrence 6) 7).

In the closed way the aim is that no air enters the subdural space. Before the dural opening the drain is tunneled beneath the galea in the direction towards the middle of the base of the skin flap. A distance from the burr hole to the drain’s exit point of at least 5 cm prevents infection 8).

Then the dura and external membrane are incised. This opening should have the same diameter as the drain to allow for a watertight and airtight drain introduction. The hematoma can therefore be evacuated only through the drain: the more fluid that is going to be collected, the more negative pressure that will be built up, which helps the brain to unfold again.

The dura is covered with a small piece of a gelatin sponge and the burr hole is filled and with bone chips collected at the beginning.

The last steps are to connect the drain to a closed collecting system and secure the connection and the exit point from the skin with sutures.




Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery. 2009 Jun;64(6):1116-21; discussion 1121-2. doi: 10.1227/01.NEU.0000345633.45961.BB. PubMed PMID: 19487891.

Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, Richards HK, Marcus H, Parker RA, Price SJ, Kirollos RW, Pickard JD, Hutchinson PJ (2009) Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet 374:1067–1073

Weigel R, Schmiedek P, Krauss JK (2003) Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:937–943

Emich S, Dollenz M, Winkler PA. Burr hole is not burr hole: technical considerations to the evacuation of chronic subdural hematomas. Acta Neurochir (Wien). 2015 Jan 13. [Epub ahead of print] PubMed PMID: 25578345.

Tosaka M, Sakamoto K, Watanabe S, Yodonawa M, Kunimine H, Aishima K, Fujii T, Yoshimoto Y (2013) Critical classification of craniostomy for chronic subdural hematoma; safer technique for hematoma aspiration. Neurol Med Chir (Tokyo) 53:273–278

Mori K, Maeda M (2001) Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371–381

Stanišić M, Hald J, Rasmussen IA, Pripp AH, Ivanović J, Kolstad F, Sundseth J, Züchner M, Lindegaard KF (2013) Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients. Acta Neurochir 155:323–333

Berghauser Pont LM, Dammers R, Schouten JW, Lingsma HF, Dirven CM (2012) Clinical factors associated with outcome in chronic subdural haematoma: a retrospective cohort study of patients on preoperative corticosteroid therapy. Neurosurgery 70:873–880

Acute Subdural Hematoma Surgical Technique

Acute Subdural Hematoma Surgical Technique

Commonly used surgical techniques for the evacuation of ASDH include cranioplastic craniotomy, large decompressive craniectomytrephination/craniostomy, or combination of these procedures. In reality, surgical techniques are not specified in most papers, and the effectiveness of surgical procedures is not addressed. For example, some institutes use decompressive craniectomies in all ASDH 1).

In case of high energy trauma and GCS ≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS ≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy 2).

While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient’s functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management 3).


Usually consists of a large craniotomy (centered over the thickest portion of the clot) to decompress the brain; to stop any active subdural bleeding; and if indicated, to evacuate intraparenchymal hematoma in the immediate vicinity of the Acute Subdural Hematoma.

Neurosurgeons frequently encounter bleeding from cortical arteries, which is usually controlled with bipolar coagulation. However, bipolar coagulation is associated with a risk of sacrificing the cortical artery, which may affect the prognosis of neurological symptoms when these cortical arteries supply critical areas.

Uneda et al., described microsurgical repair of damaged cortical arteries using a 10-0 nylon micro-suture in patients with arterial-origin ASDH 4).

Decompressive craniectomy

It is supported that decompressive craniectomy significantly improve outcome in patients with refractory intracranial hypertension due to extensive contusion, compared to routine craniotomy. However, as it has been known that bony decompression result in apparent exacerbation of edema, the superiority of decompressive craniectomy to craniotomy is still controversial.

Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis 5).


Trephination is a quick and easy technique to reduce ICP by evacuating hematoma. However, hematoma evacuation may often result in partially, ICP reduction may be often temporary, and hemostasis may not be obtained occasionally. Thus, emergency trephination should be followed by craniotomy or craniectomy. In recent years, trephination has been also applied as a minimum invasive procedure for elderly or patients with certain risks for craniotomy or craniectomy. As another aspect of trephination, hematoma irrigation with trephination therapy (HITT) has been also applied6).

Endoscopic surgery

After performing the small craniotomy, a 4-mm rigid endoscope was inserted and the hematoma was evacuated. Endoscopic surgery was performed under general or local anesthesia. The bleeding origin was a cortical artery in 2 cases, a bridging vein in 2 cases, and unknown in 1 case. The hematoma was completely removed without re-bleeding and the procedure was lifesaving in all cases. Three patients were discharged with independent gait following rehabilitation whereas 2 patients died due to causes unrelated to ASDH. Despite some surgical limitations, neuroendoscopic hematoma evacuation of ASDH is a safe and effective method that minimizes operative complications in some cases. Small craniotomy was sufficient for inserting and maneuvering ordinal neurosurgical instruments 7).

While endoscopic minimally invasive approaches to chronic subdural collections have been successfully demonstrated, this technique was reported for the first time with an 87-year-old patient presenting with a large acute right-sided subdural hematoma successfully evacuated via an endoscopic minimally invasive technique 8).

Endoscopic hematoma evacuation of acute and subacute SDH is a safe and effective method of clot removal that minimizes operative complications. This technique may be a less invasive method for treating elderly patients with acute and subacute SDHs. 9).




Kotwica Z, Brzeziński J. Acute subdural haematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien). 1993;121(3-4):95-9. PubMed PMID: 8512021.

Ruggeri AG, Cappelletti M, Tempestilli M, Fazzolari B, Delfini R. Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center. J Neurosurg Sci. 2018 Sep 25. doi: 10.23736/S0390-5616.18.04502-2. [Epub ahead of print] PubMed PMID: 30259718.

Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol. 2018 Jul 18;20(8):34. doi: 10.1007/s11940-018-0518-1. Review. PubMed PMID: 30019165.

Uneda A, Hirashita K, Yabuno S, Kanda T, Suzuki K, Matsumoto A, Yunoki M, Yoshino K. Repair of damaged cortical artery by direct micro-suture in surgical treatment of acute subdural hematoma: technical note. Acta Neurochir (Wien). 2018 Oct;160(10):1931-1937. doi: 10.1007/s00701-018-3634-5. Epub 2018 Jul 31. PubMed PMID: 30066190.

Rush B, Rousseau J, Sekhon MS, Griesdale DE. Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis. World Neurosurg. 2016 Apr;88:25-31. doi: 10.1016/j.wneu.2015.12.034. Epub 2015 Dec 31. PubMed PMID: 26748175; PubMed Central PMCID: PMC4833577.

Aruga T, Mii K, Sakamoto T, Yamashita M, Sasaki M, Tsutsumi H, Toyooka H, Takakura K. [Significance of hematoma irrigation with trephination therapy (HITT) in the management of acute subdural hematoma]. No To Shinkei. 1984 Jul;36(7):709-16. Japanese. PubMed PMID: 6487438.

Ichimura S, Takahara K, Nakaya M, Yoshida K, Mochizuki Y, Fukuchi M, Fujii K. Neuroendoscopic hematoma removal with a small craniotomy for acute subdural hematoma. J Clin Neurosci. 2019 Mar;61:311-314. doi: 10.1016/j.jocn.2018.11.043. Epub 2018 Nov 22. PubMed PMID: 30472341.

Codd PJ, Venteicher AS, Agarwalla PK, Kahle KT, Jho DH. Endoscopic burr hole evacuation of an acute subdural hematoma. J Clin Neurosci. 2013 Dec;20(12):1751-3. doi: 10.1016/j.jocn.2013.02.019. Epub 2013 Aug 17. PubMed PMID: 23962631

Yokosuka K, Uno M, Matsumura K, Takai H, Hagino H, Matsushita N, Toi H, Matsubara S. Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients. J Neurosurg. 2015 Apr 24:1-5. [Epub ahead of print] PubMed PMID: 25909568.
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