Primary Enlarged Craniotomy in Organized Chronic Subdural Hematomas

Abstract

The aim of the study is to evaluate the efficacy of craniotomy and membranectomy as initial treatment of organized chronic subdural hematoma (OCSH). We retrospectively reviewed a series of 34 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or contrast computer tomography (CCT) in order to establish the degree of organization and determine the intrahematomal architecture. The indication to perform a primary enlarged craniotomy as initial treatment for non-liquefied chronic subdural hematoma (CSDH) with multilayer loculations was based on the hematoma MRI appearance-mostly hyperintense in both T 1 -and T 2 -weighted images with a hypointense web-or net-like structure within the hematoma cavity. The reason why some hematomas evolve towards a complex and organized architecture remains unclear; the most common aspect to come to light was the "long standing" of the CSDHs which, in our series, had an average interval of 10 weeks between head injury and initial scan. Recurrence was found to have occurred in 2 patients (6% of cases) in the form of acute subdural hematoma. One patient died as the result of an intraventricular and subarachnoid haemorrhage, while 2 patients (6%) suffered an haemorrhagic stroke ipsilateral to the OCSH. Eighty-nine percent of cases had a good recovery, while 11% remained unchanged or worsened. In select cases, based on the MRI appearance, primary enlarged craniotomy seems to be the treatment of choice for achieving a complete recovery and a reduced recurrence rate in OCSH.

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

“…This form of CSDH is different from typical CSDH which consist of a brous capsule made up of inner and outer membranes lled with bloody uid. 3) It is not known why some CSDHs become organized against hyper brinolytic activity known to be the pathogenesis of typical CSDH. The neomembrane in OCSH is similar to granulation tissue.…”

“…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.…”

“…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. Balevi M and Callovini GM et al have published a large number of cases.…”

Efficacy of Middle Meningeal Artery Embolization for Organized Chronic Subdural Hematoma

“…2,3,4) It has been reported that recurrence occurred in 8-37% despite craniotomy, 2) hence various surgical treatment, such as hematoma removal by extensive craniotomy with membranectomy and dura-inner membrane adhesion, have been performed to improve curability. 6,7,8) However, invasive surgery under general anesthesia does not necessarily improve postoperative prognosis depending on the general condition and concomitant diseases. In the elderly patients, general anesthesia and surgical stress may cause the unfavorable states, such as convulsive seizure and reduction of cognitive function.…”

Há Indicação de Craniotomia para Tratamento do Hematoma Subdural Crônico?

“…Weigel et al recomendam a craniotomia como última opção, quando há recidiva do HSDCr 43 . Para muitos autores a craniotomia é o tratamento de escolha quando o hematoma se apresenta organizado, heterogêneo e multilocular em exames de imagem (Figura 1) 6,12,17,28,31,34,40,42 , a fim de permitir a expansão do cérebro 13 e evitar recidivas 6,23,37 . Outras indicações citadas são a presença de coágulos sólidos, a não expansão do cérebro após as trepanações e a presença substancial de componente agudo.…”