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Table of Contents
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 126-131

Outcome of craniotomy and membranectomy in the management of chronic subdural haematoma recurrence: A series of 17 patients

Departement of Medecine, Faculty of Medecine, Algiers University; Department of Neurosurgery, Mohamed Lamine Debaghine University Hospital (BEO), Algiers, Algeria

Date of Submission28-Jan-2022
Date of Decision27-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication21-Sep-2022

Correspondence Address:
Adel Khelifa
Departement of Medecine, Faculty of Medecine, Algiers University Algiers
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_10_22

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Background: Chronic subdural hematoma (CSDH) is a proportionally frequent neurosurgical pathology, and burr hole craniotomy is the most commonly used procedure in its treatment. However, currently, there is no real consensus on its management, especially recurrences. Many authors forwarded each management modality for the recurrence of CSDH; bone flap craniotomy was less frequently defended. Aims and Objectives: we aim to confirm the superiority of bone flap craniotomy with membranectomy over other techniques in the management of CSDH recurrences. Materials and Methods: We studied retrospectively 17 patients operated on at our department from February 2016 to February 2020, for particular situations of CSDH recurrence. Results: 17 patients with recurrent chronic subdural hematomas were operated on with bone flap craniotomy and membranectomy; with main age of 67 years old. Only one patient (5.8 %) presented recurrence of the hematoma after bone flap craniotomy. We have got one case (5.8%) of suspect osteitis on the bone flap managed successfully. Unfortunately, one patient in this series died. Conclusion: In careful surgical hands, the bone flap is not more harmful than other surgical procedures and it is found to be effective in CSDH recurrence management.

Keywords: Bone flap craniotomy, burr-hole craniostomy, chronic subdural haematoma, membranectomy, neurosurgical pathology

How to cite this article:
Bennafaa T, Khelifa A, Bennabi W, Felissi Y, Aichaoui F, Morsli A. Outcome of craniotomy and membranectomy in the management of chronic subdural haematoma recurrence: A series of 17 patients. Hamdan Med J 2022;15:126-31

How to cite this URL:
Bennafaa T, Khelifa A, Bennabi W, Felissi Y, Aichaoui F, Morsli A. Outcome of craniotomy and membranectomy in the management of chronic subdural haematoma recurrence: A series of 17 patients. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:126-31. Available from: http://www.hamdanjournal.org/text.asp?2022/15/3/126/356414

  Introduction Top

Chronic subdural haematoma (CSDH) is a frequent pathology in neurosurgery. However, there are still controversies regarding the best management of this particular type of intracranial haemorrhage.[1],[2] It often affects men with a sex ratio of 5.[3] Regarding literature, there are numerous methods to manage CSDH such as craniotomy/craniectomy with or without removal of the membranes, trephination with irrigation and twist-drill (TD) craniotomy. Currently, burr-hole craniotomy (BHC) (with drainage) is the most used method in the therapeutic protocol;[4] in this procedure, even if the intracranial pressure becomes normal, residues of the haematoma may persist and some of these residues pose an indication for surgery. The recurrence of CSDH is defined as the appearance of neurological signs within 6 months post-operative, which correlates with neuroimaging (ipsilateral re-accumulation of the haematoma).[2],[5],[6] A recurrence on two or more occasions is considered a refractory state of CSDH.[7] Among the published series, recidivism rates generally vary between 2% and 33%.[4] For CSDHs operated by trepanning, 7%‒26.5% had significant recurrences.[8] Bone flap craniotomy for the management of CSDH recurrence is not well accepted by some authors; in fact, they find it invasive without clear advantages; in our study, we aim to clarify the place of this procedure for the management of CSDH and we defend its safety if performed carefully.

  Methods Top

Patient population

We retrospectively studied the patients operated on at our department from February 2016 to February 2020, with bone flap craniotomy for CSDH recurrence. Patients treated initially with craniotomy for particular considerations were excluded from the study. The cases were presented at our emergency room where they underwent emergency brain computed tomography (CT) in all cases and brain magnetic resonance imaging (MRI) in some patients.

Surgical procedure

All patients in this series underwent initially a BHC; after failure, the management consisted of either repeating the same approach one or two times or switching directly to a craniotomy when the previous procedure finds a rigid haematoma, which cannot be washed out by saline irrigation. The craniotomy technique consists of performing, under general anesthesia, a fronto temporo parietal bone flap; then coagulation of the middle meningeal artery branches; after that, a large opening of the dura is created. The dura is easily separated with a dissector from the external membrane of the hematoma [Figure 1]d. Once the hematoma is exposed, removal of its thick outer membrane is performed along with the hematoma evacuation. In most of our cases, we remove also the inner membrane using a hydrodissection technique to avoid any traction on the cortex and therefore do not cause brain damage [Figure 1]g and [Figure 2]e, [Figure 2]f. The Hydrodissection technique consists of a small opening of the internal capsule where no adherence with the cortex is present; then injecting normal saline allowing this sheet to be separated from the cortex and safely resected afterwards; however, when the inner membrane is adherent to the arachnoid surface and the bridge veins, it is mandatory to avoid any traction or harsh maneuver on this internal membrane; in this situations, we recommend to remove only the non-adherent parts.
Figure 1: Images from case 1. (a) Brain CT objectifying a heterogeneous, right frontoparietal, chronic subdural haematoma. (b) Brain CT control after the right frontal BHC; objectifying the persistence of the collection, with shift effect on the brain. (c) Brain CT after the second BHC's surgery; objectifying the persistence of the collection and the presence of iatrogenic contusion (black arrow). (d) Right frontoparietal bone flap, evacuation of the haematoma, and outer membranectomy (white star) were performed. (e) Opening of the internal capsule. (black star: the inner membrane). (f) Removal of the inner membrane after using a hydrodissection technique. (g) Brain decompressed after membranectomy (black arrow: the brain contusion). (h) Brain CT control objectifying regression of the collection and there was no compression on the brain. CT: Computed tomography, BHC: Burr-hole craniostomy

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Figure 2: Images from case 2. (a) Brain CT objectifying the right hemispheric CSDH. (b) Brain CT control; objectifying persistence of the collection that gained more volume. (c) Brain CT control after the second BHC surgery, objectifying the persistence of the collection. (d) Large opening of the dura easily separated from the outer membrane (white star: dura; black star: outer membrane). (e and f) Removal of the outer membrane and the haematoma (lozenge: the haematoma). (g) Removal of the inner membrane after using a hydrodissection technique. (h) Brain decompressed after membranectomy. (i) Brain CT control showed a total regression of the collection. CT: Computed tomography, BHC: Burr-hole craniostomy, CSDH: Chronic subdural haematoma

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  Results Top

After the failure of initial burr-hole procedure, 17 patients with recurrent CSDH were operated on with bone flap craniotomy and membranectomy: 10 (59%) males and 7 (41%) females with age range between 12 and 87 years; 11 (65%) patients were over 70 years old; and the main age was 67 years. Anticoagulant treatment was noted in 6 (35%) patients: Vitamin K antagonists in 1 patient and platelet antiaggregant alone in 5 patients and association with heparin in 1 patient. All cases were managed initially with BHC; craniotomy was used for the first recurrence in 7 (41%) patients, for the second recurrence in 8 (47%) patients and the third recurrence in 2 (11%) patients. Only 1 (5.8%) patient presented recurrence of the haematoma after bone flap craniotomy and was managed in one more procedure consisting of the evacuation of the collection through the same approach. There was 1 (5.8%) case of suspect osteitis on the bone flap managed successfully. Unfortunately, one patient in this series died. It was an 87-year-old female, who was received initially in a bad condition with a deep conscientious disorder. She scored 9/15 on Glasgow Coma Scale, and she presented bedsore. Initially, her management consisted of performing an evacuation of the haematoma through BHC; this procedure failed to improve the consciousness disorder. The second surgical time consisted of performing an evacuation through craniotomy with membranectomy. The postoperative clinical examination was marked by a consciousness improvement evaluated at 13/15, but 4 days later, she presented suddenly with a heart arrest and resuscitation failed [Table 1].
Table 1: Summary of recurrence cases of chronic subdural haematoma managed with craniotomy and membranectomy

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Representative cases

Case 1

Case 1 [Figure 1] is a 71-year-old male with a medical history of diabetes, benign prostatic hyperplasia and high blood pressure. The patient was a victim of slight cranial trauma 3 weeks before his consultation. At the admission, he was consciously presenting a weakness of the left hemibody. The brain CT objectified a heterogeneous, right frontoparietal, CSDH [Figure 2]a; initially, the haematoma was evacuated through one frontal burr hole; in the post-operative, the patient improved clinically. Twelve days later, the weakness reappeared in the brain CT objectified the persistence of the collection, with a shift effect on the brain [Figure 2]b; hence, the patient was readmitted to the operating room and the haematoma was evacuated through the same frontal burr hole with another parietal one; there was no improvement. Twenty-four h later, there was an impairment of the consciousness estimated at 12/15 on the Glasgow Coma Scale; the brain CT objectified the persistence of the collection and appearance of what seems to be an iatrogenic contusion [[Figure 2]c, arrow]; the patient was operated and this time, we performed a frontoparietal bone flap through which the haematoma was evacuated [Figure 2]d, and a membranectomy was performed [Figure 2]d, [Figure 2]e, [Figure 2]f, [Figure 2]g; in post-operative, the patient immediately improved his consciousness and gradually the weakness disappeared. Control brain CT was performed a week later, objectified a regression of the collection and there was no compression on the brain [Figure 2]h.

Case 2

Case 2 [Figure 2] is a 76-year-old female with a medical history of high blood pressure and heart disease; the patient was operated on 11 years before for a left CSDH and the collection was evacuated through two burr holes. She consulted for 1 week's history of headache and vomiting. The clinical examination found a discreet left hemiparesis. Brain CT was performed on the objectified right (contralateral) hemispheric CSDH [Figure 2]a; initially, the collection was evacuated through two right burr holes. After her discharge and 2 weeks after the surgery, the patient was re-consulted for dysarthria and facial palsy; brain CT objectified the persistence of the collection that gained more volume applying more pressure on the brain [Figure 2]b; again, the collection was evacuated through the same burr holes; there was no remarkable improvement; a brain CT objectified the persistence of the collection [Figure 2]c. This time, the haematoma was totally evacuated through a bone flap craniotomy, and a large opening of the dura [Figure 2]d and membranectomy was performed [Figure 2]e, [Figure 2]f, [Figure 2]g, [Figure 2]h; in post-operative, there was a clinical improvement. The control brain CT showed a total regression of the collection and the space was regained by the brain [Figure 2]i.

  Discussion Top

CSDH is one of the most frequent pathologies in neurosurgery; the initial management is considered simple, and in most times, the hematoma is evacuated through one or two burr holes. Subdural space is a layer of cells called dural border cells.[1],[3],[9] Head trauma could be the primum movens of the CSDH formation; in fact, this trauma would cause an injury in the border cells and so, launching an inflammatory process. Chronic inflammation forms the outer membrane with its fragile neovascularisation, a source of blood leakage in the subdural space where cerebrospinal fluid was initially spelt. Secondary the inner membrane is formed and the hematoma is then encapsulated. Blood leakage persists along with the inflammatory process leading to an increase in both the thickness of the membrane, and the collection volume, and so, leading to more brain compression and an increase in cranial pressure, those two are both responsible for the symptoms' appearance.[1],[9] This is what was observed in all our patients operated by the same neurosurgical team for CSDH recurrence; in fact, through the BHC it was noticed that the outer membrane becomes harder and thicker each time; which leads to shielding of the collection, difficult to manage by a simple burr hole; thus, we estimate that this situation requires a very large excision of membranes, which is feasible through a bone flap craniotomy. The hematoma could be the consequence of bleeding of different ages; and because each time there is bleeding the collection creates its own membrane, the subdural space will contain multiple collections in different chambers, separated one from others by membranes leading to isolate one collection from the others and made the management more difficult. The clinical presentation is very wide and nonspecific; it begins usually at least 2 weeks, after a minor unremarkable traumatism.[1],[2],[3],[9] In old patients, the clinical presentation is dominated by cognitive disturbance and hemibody weakness; in younger people, increasing intracranial pressure is more frequent; other presentations include seizures and focal deficit.[3] In 1974, Bender and Christoff proposed a classification of the clinical presentations of CSDH; this classification is widely adopted [Table 2].[10] Brain CT in most cases is sufficient for diagnosis; classically, it shows a hypodense hemispheric lenticular extraparenchymal collection, with a shift effect. Frequently, the collection is formed of two or more levels of different densities; the lower level is hyperdense presenting sediment of new bleeding, and the higher level is the usual hypodense chronic blood.[3] MRI is rarely performed; it objectifies the collection in hyposignal on T1-weighted images and hypersignal on T2-weighted images and membranes are more visible. In the case of Bender I clinical presentation, medical treatment could be a choice; it is based on hydration and corticosteroids with close observation and imaging every month;[1],[2],[3],[8],[9] otherwise, surgical management is indicated and will be urgent, especially in the case of Bender III or IV clinical presentations. Multiple surgical techniques are available; classically, BHC is the method of choice for the initial management of CSDH; it is considered to be simple, fast, efficient and with minimal risks.[5],[6] Recurrence is considered when there is worsening or even persistence of the symptomatology correlated with radiological findings within 6 months;[2],[5],[6] the persistence of the collection on imaging without clinical correlation is not considered in most times as recurrence. All treatment modalities were described in the literature to be used in the management of CSDH recurrences,[2],[3],[5],[6],[8] and many authors defended each technique. Zhang et al.[2] treated 24 CSDH recurrences -initially operated with either BHC or TD- with 4 mg of dexamethasone every 8 hours for 3 days: 17 patients of their patients were relieved of their symptoms. But initially, the patients' selection was based on a Glasgow Coma Scale >13; and for patients without immediate brain herniation risks. One patient of their series presented extensive membranes and was treated successfully with craniotomy after the failure of each BHC and dexamethasone treatment. BHC is the management of choice for many surgeons;[6],[8] in most cases, we consider that a second or even third time of BHC could be sufficient for brain decompression. Multiples clinical and radiological findings are predicting factors for the recurrence of CSDH after BHC such as diabetes mellitus, antiplatelet and anticoagulant drugs, bilateral CSDH, postoperative midline shifting, and membrane septation;[5],[11] in such cases, craniotomy management is rational. Based on T2-weighted image MRI, Tanikawa et al. found that collection which appeared to have a multilayer intrahaematomal structure had a high recurrence rate; their team treated 16 patients with craniotomy without complications.[12] Mohamed reported a series of 39 patients managed successfully with craniotomy, durectomy, outer membranectomy and subgaleal suction drainage, without additional complications; one of his patient selection criteria was the presence of intrahaematoma membranes on MRI.[13] In addition, we believe that the previous intraoperative finding (during BHC) is essential to identify the thickness and hardness character of the capsules and the non-expansion of the brain, to choose the best attitude for the management of recurrence. We use craniotomy for the recurrences of haematomas with massive acute components, extensive membranes and in case of multi failure of BHC, especially in fragile patients with diabetes or anticoagulant treatment. Theoretically, the evacuation of the collection through BHC could be impossible because of the thick septations that isolate the collection under the burr hole from other collections; and so the compression persists. Moreover, a thick membrane could present itself as compression, and its persistence could perpetuate the bleeding through its fragile vessels. Thus, it is evident that the membranectomy through a craniotomy could be the final and efficient solution for CSDH recurrence. In fact, in the 17 patients of CSDH recurrence managed with craniotomy and membranectomy of our series, only one patient needed a second-time evacuation after this procedure, this case presents 5.8% of our series; when an overall recurrences rate of up to 33% of all techniques included is found in Liu, et al.[6] in their meta-analysis. The ventriculoperitoneal shunt is known to be a recurrence factor;[8] in a series of patients with CSDH complicating ventricular shunt, Assoumane et al.[14] got four recurrences (25%) after initial management; two of those patients were children managed successfully with craniotomy without complications. Finally, even though the burr hole is considered to be the safest way to evacuate a hematoma, in case of recurrence, BHC is not always without risks[2],[6] [e.g.: the brain contusion in the first case, [Figure 2]b, and [Figure 2]g; and it seems more rational to switch to more radical management than multiplying operations that are not totally unharmful. According to Hamilton et al., the craniotomy does not deserve its bad reputation;[15] in fact, the one case of mortality in the presented series seems to have no relation to the procedure; a patient of 87-years-old was received the first time in a very bad condition, despite that, after craniotomy, she improved, until the 4th day when she suddenly died. In another case, there was a suspicion of osteitis of the bone flap that was managed easily; otherwise, there were no significant complications for the procedure.
Table 2: Bender and Christoff classification for chronic subdural haematoma clinical presentation

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  Conclusion Top

Once we get a view of the CSDH pathology, we understand that the presence of thick or multiple membranes could perpetuate the bleeding, and because of that all management modalities will fail, except the removal of the membrane itself. In careful surgical hands, the bone flap is not more harmful than other surgical procedures and it is found to be effective in CSDH recurrence management.

Ethical clearance

The study has been conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013).In fact, this study did not include any experimental procedures on humans or animals; it only reports and analyzes the results from patient management with well-accepted tools in the scientific community.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Holl DC, Volovici V, Dirven CM, Peul WC, Kooten FV, Jellema K, et al. Pathophysiology and nonsurgical treatment of chronic subdural hematoma: From past to present to future. World Neurosurg 2018;116:402-11.  Back to cited text no. 1
Zhang Y, Chen S, Xiao Y, Tang W. Effects of dexamethasone in the treatment of recurrent chronic subdural hematoma. World Neurosurg 2017;105:115-21.  Back to cited text no. 2
Alliez JR, Balan C, Kaya JM, Leone M, Reynier Y, Alliez B. Hématome sous-dural chronique de l'adulte. Neurologie 2007;4:1-9. 17-585-A-30. Doi : 10.1016/S0246-0378(07)46312-6.  Back to cited text no. 3
Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, et al. Chronic subdural hematoma management: A systematic review and meta-analysis of 34829 patients. Ann Surg 2014;259:449-57.  Back to cited text no. 4
Kim SU, Lee DH, Kim YI, Yang SH, Sung JH, Cho CB. Predictive factors for recurrence after burr-hole craniostomy of chronic subdural hematoma. J Korean Neurosurg Soc 2017;60:701-9.  Back to cited text no. 5
Liu W, Bakker NA, Groen RJ. Chronic subdural hematoma: A systematic review and meta-analysis of surgical procedures. J Neurosurg 2014;121:665-73.  Back to cited text no. 6
Matsumoto H, Hanayama H, Okada T, Sakurai Y, Minami H, Masuda A, et al. Which surgical procedure is effective for refractory chronic subdural hematoma? Analysis of our surgical procedures and literature review. J Clin Neurosci 2018;49:40-7.  Back to cited text no. 7
Desai VR, Scranton RA, Britz GW. Management of recurrent subdural hematomas. Neurosurg Clin N Am 2017;28:279-86.  Back to cited text no. 8
Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KL, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: Inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017;14:108.  Back to cited text no. 9
Bender MB, Christoff N. Nonsurgical treatment of subdural hematomas. Arch Neurol 1974;31:73-9.  Back to cited text no. 10
Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M, Yamagata S. Independent predictors for recurrence of chronic subdural hematoma: A review of 343 consecutive surgical cases. Neurosurgery 2008;63:1125-9.  Back to cited text no. 11
Tanikawa M, Mase M, Yamada K, Yamashita N, Matsumoto T, Banno T, et al. Surgical treatment of chronic subdural hematoma based on intrahematomal membrane structure on MRI. Acta Neurochir (Wien) 2001;143:613-8.  Back to cited text no. 12
Mohamed EE. Chronic subdural haematoma treated by craniotomy, durectomy, outer membranectomy and subgaleal suction drainage. Personal experience in 39 patients. Br J Neurosurg 2003;17:244-7.  Back to cited text no. 13
Assoumane I, Al Zekri M, Khelifa A, N Touati, N Lagha, A Sidi Said, et al. Subdural hematoma complicating ventriculoperitoneal shunts: An Algerian centers experience. Indian J Neurosurg 2020;9:147-50. [doi: 10.1055/s-0039-3402592].  Back to cited text no. 14
Hamilton MG, Frizzell JB, Tranmer BI. Chronic subdural hematoma: The role for craniotomy reevaluated. Neurosurgery 1993;33:67-72.  Back to cited text no. 15


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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