Organized chronic subdural hematomas treated by large craniotomy with extended membranectomy as the initial treatment

Abstract

Objective:The aim of this retrospective study is to evaluate the efficacy and incidence of complications of craniotomy and membranectomy in elderly patients for the treatment of organized chronic subdural hematoma (OCSH).Materials and Methods:We retrospectively reviewed a series of 28 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or computer tomography (CT) to establish the degree of organization and determine the intrahematomal architecture including inner membrane ossification. The indication to perform a primary enlarged craniotomy as initial treatment for nonliquefied OCSH with multilayer loculations was based on the hematoma MRI appearance – mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity or inner membrane calcification CT appearance - hyperdense. These cases have been treated by a large craniotomy with extended membranectomy as the initial treatment. However, the technique of a burr hole with closed system drainage for 24–72 h was chosen for cases of nonseptated and mostly liquefied Chronic Subdural Hematoma (CSDH).Results:Between 1998 and 2015, 148 consecutive patients were surgically treated for CSDH at our institution. Of these, 28 patients which have OSDH underwent a large craniotomy with extended membranectomy as the initial treatment. The average age of the patients was 69 (69.4 ± 12.1). Tension pneumocephalus (TP) has occurred in 22.8% of these patients (n = 28). Recurring subdural hemorrhage (RSH) in the operation area has occurred in 11.9% of these patients in the first 24 h. TP with RSH was seen in 4 of 8 TP patients (50%). Large epidural air was seen in one case. Postoperative seizures requiring medical therapy occurred in 25% of our patients. The average stay in the department of neurosurgery was 11 days, ranging from 7 to 28 days. Four patients died within 28 days after surgery; mortality rate was 14.28%.Conclusion:Large craniotomy and extended membrane excision for OSDH still carry a high rate of mortality and morbidity in elderly patients. TP, RSH, and postoperative seizures are frequently seen complications in elderly patients.

Enlarged Craniotomy with Membranectomy for Treatment of Completely Organized Chronic Subdural Hematoma: A Case Report and Literature Review

“…13) Recent evidence suggests that large craniotomies for organized subdural hematomas provides a superior and safer opportunity to adequately deal with the hematoma, its membranes, and occasional bleeding. 3,9,10) Moreover, extended outer and inner membranectomy is important for expansion of subdural space. 9) The outer membrane is related to hematoma enlargement due to repetitive hemorrhages, while the inner membrane is related to liquefaction of the subdural hematoma.…”

“…3,9,10) Moreover, extended outer and inner membranectomy is important for expansion of subdural space. 9) The outer membrane is related to hematoma enlargement due to repetitive hemorrhages, while the inner membrane is related to liquefaction of the subdural hematoma. 9,14) The complications of enlarged craniotomy mainly include tension pneumocephalus, recurring subdural hemorrhage, and postoperative seizures.…”

“…9) The outer membrane is related to hematoma enlargement due to repetitive hemorrhages, while the inner membrane is related to liquefaction of the subdural hematoma. 9,14) The complications of enlarged craniotomy mainly include tension pneumocephalus, recurring subdural hemorrhage, and postoperative seizures. 3) There are few cases of completely OCSH treated by enlarged craniotomy.…”

Recurrence of Chronic Subdural Hematomas Requiring Reoperation: Could Small Trephination Be a Valid Alternative to Conventional Approaches?

“…[39] Similar results were encountered in Balevi's cohort which included 148 patients with surgically treated CSDH's, 28 of them being operated by large craniotomy with inner membrane excision. [41] The latter group associated a recurrence rate of 28.5%, while the reported rate associated to burr hole drainage is 4%-8%. [42] Given the high recurrence rate associated with inner membranectomy that we observed, we do not recommend performing this surgical manoeuvre.…”

Inner membrane opening during the burr-hole evacuation of a chronic subdural hematoma: risk-adding or recurrence-preventing?

“…Inner membrane opening was discussed during craniotomy for CSDH in many studies [10][11][12][13][14][15][16], but only a few studies had mentioned the opening of the inner membrane during the burr-hole evacuation of a CSDH [17,18].…”