Chronic Subdural Hematoma Surgical Technique [Neurosurgery Wiki]

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====== Chronic Subdural Hematoma Surgical Technique ======

//J.Sales-Llopis//

//Neurosurgery Service, Alicante University General Hospital, Spain.//
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{{ ::chronic_subdural_hematoma_surgical_technique.jpg?300|}}

===== Latest Pubmed Related Articles =====

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/16eWR_JeA5ggz7lp6exRXyljdv1Bg_b5daAnspofyJehJ6_wD-/?limit=15&utm_campaign=pubmed-2&fc=20230404175558}}
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There is lack of uniformity about the treatment strategies, such as the role of [[burr hole]], [[twist drill]], [[craniotomy]], etc., in CSDH amongst various surgeons. There is also disagreement about the use of [[drain]], [[irrigation]], and [[steroid]]
((Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of
primary chronic subdural haematoma: a questionnaire survey of practice in the
United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008
Aug;22(4):529-34. doi: 10.1080/02688690802195381. PubMed PMID: 18686063.
))
((Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a
national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6.
PubMed PMID: 16408582.)).
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[[Twist drill craniostomy]], [[Burr hole trephination]], and standard [[craniotomy]] have similar neurologic outcomes in elderly patients. The presence of thick [[membrane]]s is a relative contra-indication for [[Twist drill craniostomy]] due to high 30-day recurrence. Patients > 80 have a higher risk of stroke and increased length of stay with standard [[craniotomy]]
((Peters DR, Parish J, Monk S, Pfortmiller D, Henegar M, Bernard J, Smith MD, Van Poppel M. Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis. World Neurosurg X. 2023 Mar 17;18:100183. doi: 10.1016/j.wnsx.2023.100183. PMID: 37013106; PMCID: PMC10066545.)).
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(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) [[Middle meningeal artery embolization for chronic subdural hematoma]]: 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]]
((Siddique AN, Khan SA, Khan AA, Aurangzeb A. Surgical Treatment [[Option]]s For Chronic [[Subdural]] Haematoma. J Ayub Med Coll Abbottabad. 2022 Jul-Sep;34(3):550-556. doi: 10.55519/JAMC-03-10225. PMID: 36377174.))
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Till 1970s, [[craniotomy]] was the most commonly used method
((Ernestus R, Beldzinski P, Lanfermann H, Klug N. Chronic subdural hematoma:
surgical treatment and outcome in 104 patients. Surg Neurol 1997;48:220–5.))
((McKissock W, Richardson A, Bloom WH. Subdural hematoma: a review of 389
cases. Lancet 1960;1:1365–9.))
((Tyson G et al. The role of craniectomy in the treatment of chronic subdural
hematomas. J Neurosurg 1980;52:776–81.))
((Putnam IJ, Cushing H. Chronic subdural hematoma. Its pathology, its relation
to pachymeningitis hemorrhagica, and its surgical treatment. Arch Surg
1925;11:329–93.)). 



[[Burr hole trephination for chronic subdural hematoma]] became the most preferred method from 1980s. 
Later [[burr hole trephination]] (BHT) was adopted because it was less invasive with lower
morbidity and recurrence rates when compared with standard
craniotomy
((Chronic Almenawer S et al. Subdural hematoma management: a systematic
review and meta-analysis of 34829 patients. Ann Surg 2014;259(3):449–57.))
((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.))
((Ducruet A et al. The surgical management of chronic subdural hematoma.
Neurosurg Rev 2012;35:155–69.))
((Leroy H et al. Predictors of functional outcomes and recurrence of chronic
subdural. J Clin Neurosci 2015;22:1895–900.))
((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.))
((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.)).

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
((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.
)).

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
((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.
)).

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
((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.))

Although nonsurgical treatment is often successful, [[trephination]] has more advantages, such as rapid resolution of the [[symptom]]s 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 recurrence]]s, 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]]
((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.
)).
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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 [[membrane]]s.

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

===== 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 =====