Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas

Abstract

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.

Benefits of the Subdural Evacuating Port System (SEPS) Procedure Over Traditional Craniotomy for Subdural Hematoma Evacuation

“…18 With the advent and commercialization of drainage systems, however, kits such as the SEPS have gained popularity and are increasingly described in the literature, particularly over the past 5 years. 4,15,17,19,20 Bedside procedures such as the SEPS provide an opportunity to avoid general anesthesia, and its hermetically sealed mechanism decreases the risk of infection—both critical advantages when treating a primarily elderly population who tend to be poor surgical candidates. 11 Our retrospective study corroborates the existing literature suggesting that the SEPS is associated with a low postoperative infection and comorbidity rate with a 0% infection rate observed in our study across nearly 40 patients.…”

Surgical Procedure in the Treatment of Organized Chronic Subdural Hematoma: A Single-Center Experience

“…1,2 Bur hole irrigation and closed-system drainage have been established as the mainstay of treatment. 3 Organized CSDH, a special type of CSDH that is composed of organized, rigid, multilayered hematoma and fibrous, thick membrane, 4 has high recurrence rates and bur hole irrigation is not sufficient. 5 Although there have been several investigations on the surgical procedure of organized CSDH, [6][7][8][9][10][11] the optimal procedure has not been established yet.…”

Transition of a Clinical Practice to Use of Subdural Drains after Burr Hole Evacuation of Chronic Subdural Hematoma: The Helsinki Experience

“…1,2 Most physicians would agree that nonsurgical treatment is recommendable with asymptomatic patients who have small CSDHs. 3 For symptomatic CSDHs, burr-hole evacuation has become the most preferred treatment method, 4,5 as it results in rapid resolution of the symptoms and a short period of hospitalisation. Other surgical options, such as using two burr-holes, twist drill craniostomy or even craniotomy in selected patient population have been used to treat CSDHs.…”

“…Other surgical options, such as using two burr-holes, twist drill craniostomy or even craniotomy in selected patient population have been used to treat CSDHs. 2,3 Up to date, there is a lack of consensus regarding the most optimal surgical technique. 6 Even among Scandinavian centres, surgical techniques differ.…”