Minicraniotomy versus bur holes for evacuation of chronic subdural collections in infants—a preliminary single-institution experience

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Various surgical interventions have been described to evacuate chronic subdural collections (CSCs) of infancy. These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. Shunt placement typically provides good long-term success (resolution of the subdural fluid), but comes with well-known early and late complications. Recently, the authors have used a mini–osteoplastic craniotomy technique with the goal of definitively treating these children with a single surgery while avoiding the many issues associated with a shunt. They describe their procedure and compare it with the traditional bur hole technique.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>In this single-institution retrospective study, the authors evaluated 26 cases involving patients who underwent treatment for CSC. Preoperative, intraoperative, and postoperative data were reviewed, including radiographic findings (density of the subdural fluid and ventricular and subarachnoid space size), neurological examination findings, and intraoperative fluid description. The primary outcome was treatment failure, defined as the patient requiring any subsequent surgical intervention after the index procedure (minicraniotomy or bur hole placement).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Fifteen patients (10 male and 5 female; median age 5.1 months) collectively underwent 27 minicraniotomy procedures (each procedure representing a hemisphere that was treated). In the bur hole group, there were 11 patients (6 male and 5 female; median age 4.6 months) with 18 hemispheres treated. Both groups had subdural drains placed. The average follow-up for each treatment group was just over 7 months. Treatment failure occurred in 2 patients (13%) in the minicraniotomy group compared with 5 patients (45%) in the bur hole group (p = 0.09). Furthermore, the 2 patients who had treatment failure in the minicraniotomy group required 1 subsequent surgery each, whereas the 5 in the bur hole group needed a total of 9 subsequent surgeries. Eventually, 80% of the patients in the minicraniotomy group and 70% of those in the bur hole group had resolution of the subdural collections on the last imaging study.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The minicraniotomy technique may be a superior technique for the treatment of CSCs in infants compared with bur hole evacuation. The minicraniotomy provides greater visualization of the subdural space and allows more aggressive evacuation of the fluid, better irrigation of the space, the ability to fenestrate any accessible membranes safely, and continued egress of fluid into the subgaleal space. Although this preliminary report has obvious limitations, evaluation of this technique may be worthy of a prospective, multiinstitutional collaborative effort.</jats:p></jats:sec>

"Rabbit Ear" scalp deformity caused by massive subdural effusion in infant following bilateral burr-hole drainage

“…[6] Subdural shunts have an inherent long-term potential morbidity. [5] Few cases may develop subarachnoid to subdural collection, which may be unrecognized and cause dependence on shunt. A second surgery may be required for its removal if it is not needed anymore.…”

“…A second surgery may be required for its removal if it is not needed anymore. [5] Klimo et al . [5] advocates most desirable procedure would be one that has the greatest chance of definitively treating the SDE as a single surgery with low risk of complications and without placing a shunt.…”

“…[123] These collections evolve following acute onset hematoma or breach of the arachnoid usually precipitated by blunt force trauma, which may occur following accident or non-accidental origin. [1245] Subdural effusion (SDE) may show spontaneous resolution or enlarge with passage of time. It may clinically present with rapid enlargement of head size, focal symptoms caused by compression over adjoining brain parenchyma or in progressively enlarging condition can produce global neurological deficits.…”

Post meningitis subdural hygroma: Anatomical and functional evaluation with 99m Tc-ehylene cysteine dimer single photon emission tomography/computed tomography

“…These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. [10] While shunt placement typically provides good long-term success it has well-known early and late complications. The minicraniotomy technique may be superior to the burr-hole method, especially in children and was employed in the present case.…”

Subdural to subgaleal shunts: alternative treatment in infants with nonaccidental traumatic brain injury?

“…Some authors still advocate the use of minicraniotomy given its good success rate, but this method is quite invasive. 3 Subduroperitoneal drainage has been the gold standard in our department for more than 15 years, and other studies have shown excellent results for this procedure, with more than 90% success. 4,5,9,17 The main advantages are a short period of hospitalization with continuous drainage and a low infection rate.…”