Elsevier

Surgical Neurology

Volume 67, Issue 4, April 2007, Pages 374-380
Surgical Neurology

Vascular
Membranectomy in organized chronic subdural hematomas: indications and technical notes

https://doi.org/10.1016/j.surneu.2006.08.066Get rights and content

Abstract

Background

The aim of the present study is to present our operative method of removing organized CSDHs and to structure the criteria for choosing this approach as first treatment.

Methods

Between 1991 and 1999 at our Institution, 14 consecutive patients with organized CSDHs required 16 craniotomies with membranectomy. They represent 5.8% of all patients (243) treated for CSDHs in the same period. All the patients had preoperative contrast-enhanced CT, and 9 patients also had contrast MRI.

Results

Initially, 9 patients underwent one burr hole or twist-drill hole. Of these 9 patients, 3 were treated at the same surgery with craniotomy and membranectomy as second treatment, 3 underwent a second burr hole and then membranectomy at the same surgery, and 3 patients underwent a second burr hole 3, 4, and 21 days after the first one and then membranectomy. Five patients underwent immediate craniotomy and membranectomy. There were no morbidity or mortality associated with this procedure. All patients had a full recovery without recurrence.

Conclusions

Contrast-enhanced MRI has greatly improved opportunities for discovering neomembrane before surgical intervention. We believe that MRI detection of thick and extensive membranes or solid clot with mass effect makes an immediate craniotomy to remove CSDH necessary.

Introduction

Since 1857, when Virchow first described CSDHs as “pachymeningitis hemorrhagica interna,” a vast variety of surgical techniques to treat this common disorder have been proposed [1]. There is a general agreement that a combination of clinical and radiographic findings, suggesting a CSDH with mass effect, indicates the surgical treatment [7], [9], [15], [16], [24], [27], [29], [32], [38], [39], [41], [44]. Some authors support the use of minimal invasive intervention (burr hole or twist-drill holes) because these techniques offer equivalent efficacy to craniotomy with lower mortality and morbidity and a shorter operating time and hospital stay [6], [24], [38]. However, burr hole outcome varies widely with a percentage of reoperation from 3% to 37% [2], [3], [16], [20], [24], [25], [32], [41], [42], [43], [44]. These failures are due mainly to residual thick hematoma membranes [16], [32], [38], [43]. The choice of the surgical technique to treat CSDHs must be dictated by the degree of organization of the hematoma. Burr hole and drainage is mandatory for nonseptated and mostly liquified CSHs. Conversely, craniotomy with membranectomy is the sole reasonable approach for CSHs organized in a solid structure.

We propose an easy technique of membranectomy that has guaranteed optimal results in our series of CSDHs.

However, the purpose of this report is not only to describe our operative method for treating organized CSDHs, but also to provide the criteria for selecting patients requiring craniotomy and membranectomy as first treatment.

Section snippets

Material and methods

Between 1991 and 1999, 243 consecutive patients were surgically treated for CSDH at our institution. We have operated on only symptomatic patients. Our treatment of choice for chronic subdural hematoma is burr hole under sedation and local anesthesia with closed system drainage for 24 to 72 hours. However, 14 of our patients required craniotomy and membranectomy. This group of patients is the subject of the present study.

The admission status of each patient was classified according to the GCS

Our protocol and surgical technique

For various years, we have removed organized SDH with a direct aggression on the hematoma membranes. However, over the last 6 years, we have adopted the following surgical procedure to perform a membranectomy.

Craniotomy limits are decided on the basis of the MRI. A large craniotomy flap is performed to expose the transition zone between external and internal hematoma membranes.

The dura is then opened and separated by the external membrane of the hematoma with a dissector. This is always a

Results

The patients included 7 men and 7 women. The mean age was 62.1 years (range, 41-76 years). Twelve patients had a history of minor head trauma occurring an average of 1.5 months before admission (range, 14 days-4 months). Previous head trauma was investigated via CT in 12 patients. One patient was dialyzed, and the remaining patients had no risk factors for the development of a CSDH. There were 7 patients with a GCS 10, 2 patients with a GCS 11, 2 patients with a GCS 12, and 3 patients with a

Discussion

Chronic subdural hematomas can be approached with several surgical techniques. The common treatment methods range from burr holes or twist-drill hole to craniotomy with removal of the hematoma thick membranes.

Actually, there is no uniform agreement on the best method to treat CSDHs [1], [7], [10], [16], [22], [23], [29], [32], [37]. The true problem, in our opinion, is to know preoperatively whether the CSDH is organized.

Contrast enhancement MRI may give useful information about the structure

Conclusion

Complete recovery obtained through a single operative procedure not only reduces surgical invasion but also lowers medical costs because of reduced hospital stay.

We believe that failure to recognize and properly treat organized CSDHs is the principal reason for the discordant results reported in the current literature. Craniotomy and membranectomy as first treatment have to be reserved only for selected cases: hematoma organized in solid structure, hematoma with multiple compartments delimited

References (46)

  • E.S. Fobben et al.

    MR characteristics of subdural hematoma and hygromas at 1.5 T

    AJR Am J Roentgenol

    (1989)
  • R.L. Friede et al.

    The origin of subdural neomembranes. II. Fine structure of neomembranes

    Am J Pathol

    (1978)
  • M. Fujioka et al.

    Bilateral organised chronic subdural haematomas: high field magnetic resonance images and histological considerations

    Acta Neurochir (Wien)

    (1994)
  • D.E. Haines

    On the question of a subdural space

    Anat Rec

    (1991)
  • D.E. Haines et al.

    The “subdural” space: a new look at an outdated concept

    Neurosurgery

    (1993)
  • N.G. Hamilton et al.

    Nonoperative management of acute epidural hematoma diagnosed by CT: the neuroradiologist's role

    AJNR Am J Neuroradiol

    (1992)
  • M.G. Hamilton et al.

    Chronic subdural hematoma: the role for craniotomy reevaluated

    Neurosurgery

    (1993)
  • J.S. Han et al.

    Head trauma evaluated by magnetic resonance and computed tomography: a comparison

    Radiology

    (1984)
  • K. Hosoda et al.

    Magnetic resonance images of chronic subdural hematomas

    J Neurosurg

    (1987)
  • O.R. Hubschmann

    Twist drill craniostomy in the treatment of chronic and subacute subdural hematoma in severely ill and elderly patients

    Neurosurgery

    (1980)
  • N. Kawano et al.

    Origin of the capsule of a chronic subdural hematoma—an electron microscopy study

    No Shinkei Geka

    (1988)
  • W.F. Krupp et al.

    Treatment of chronic subdural hematoma with burr hole craniostomy and closed drainage

    Br J Neurosurg

    (1985)
  • R. Laumer et al.

    Implantation of a reservoir for recurrent subdural hematoma drainage

    Neurosurgery

    (1989)

    • Cited by (53)

    • Updates in Chronic Subdural Hematoma: Epidemiology, Etiology, Pathogenesis, Treatment, and Outcome

      2020, World Neurosurgery

    • Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported During Last Century with a Demonstrative Case Report

      2020, World Neurosurgery
      Citation Excerpt :

      Most recently, Fang et al.154 reported an extremely rare case of ossified CSDH in a 7-year-old child, with a literature review, and stressed the importance of differential diagnosis in the presence of an intracranial placeholder. Technically, surgery under general anesthesia with a low recurrence rate and lesser complications is indicated3,56,61,90,120,121,138,154,155 Furthermore, an extended membranectomy technique is recommended with large craniotomy in patients with significant membranes,151 multiloculated,156 organized,139,141,142,157 and calcified or ossified CSDHs.138 Using a microsurgical dissection technique, thick and extensive calcified or ossified membrane could be excised from brain surface3 or drilled by high-speed air drill until pulsation of the brain was visualized through the inner membrane,4,90 but it can result in cerebral contusion and permanent neurologic deficits in patients with calcified or ossified CSDH.120,127,158

    • Independent Risk Factors for Postoperative Seizures in Chronic Subdural Hematoma Identified by Multiple Logistic Regression Analysis

      2019, World Neurosurgery

    • Burr hole craniostomy with novel use of subdural drain for evacuation of chronic subdural hematoma: Case series, literature review, and technical note

      2019, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management

    • Description of a Modified Technique (mini craniotomy–basal membranotomy) for Chronic Subdural Hematoma Surgery and Evaluation of the Contribution of Basal Membranotomy Performed as Part of This Technique to Cerebral Expansion

      2019, World Neurosurgery

    • Burr Hole Surgery for Chronic Subdural Hematoma with Extensive Scalp Burn

      2018, World Neurosurgery
    View all citing articles on Scopus
    View full text
    Copyright © 2007 Published by Elsevier Inc.