Chronic subdural hematoma: surgical treatment and outcome in 104 patients.

BACKGROUND: The common occurrence of chronic subdural hematoma (CSDH) in older patients raises some diagnostic and therapeutic difficulties. Despite general agreement about the indication of operation, the extent of surgery is still discussed controversially. We have, therefore, reviewed operative findings and outcome in 104 patients with CSDH.

METHODS: Retrospective analysis was performed by differentiating age < or = 60 years (n = 28) versus age > 60 years (n = 76) and burr hole craniostomy with a size range from 12-30 mm (n = 94) versus larger craniotomy (n = 10). All patients received closed-system drainage of the subdural space for 2-4 days.

RESULTS: Four patients older than 60 years died within 30 days after surgery, two in each operative group. Excluding these postoperative deaths, 17 out of 92 patients (18.5%) after burr hole trepanation and one out of eight patients (12.5%) after craniotomy required reoperation due to rebleeding (n = 6), residual subdural fluid (n = 4), and residual thick hematoma membranes (n = 8). Eight patients, who had been initially treated by burr hole craniostomy despite preoperative detection of neomembranes by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), recovered without further intervention. Clinical outcome was good in both operative groups. The percentage of patients without or with only mild neurologic deficits at the time of discharge from the hospital was 72.3% in the burr hole and 70.0% in the craniotomy group, respectively.

CONCLUSIONS: The clinical data of the present study suggest that burr hole craniostomy with closed-system drainage should be the method of choice for the initial treatment of CSDH, even in cases with preoperative detection of neomembranes. Craniotomy should be carried out only in patients with reaccumulating hematoma or residual hematoma membranes, which prevent reexpansion of the brain.