Trephine Craniotomy and
Cisternal Drainage for Chronic Subdural Haematomas: Preliminary report
de la Policia Nacional and Hospital
Militar , Guayaquil –Ecuador.
cases of chronic subdural haematoma were operated performing a small trephine
craniotomy ,membranectomy and cisternal drainage ,with excellent outcome. We
think that this method is especially indicated in haematomas with solid clots ,thick
membranes and multiple loculations. This procedure assures rapid decompression
and re-expansion of the collapsed brain by re-establishing the
CLF circulation on the brain convexity.
Trephine Craniotomy ,
membranectomy , cisternal
first described in 1857 the
chronic subdural haematomas and called it “Paquimeningitis
was considered at that time a fatal disorder.
principal techniques used in the treatment of chronic subdural hematomas are
presently twist drill craniostomy, burr hole craniostomy and craniotomy,
.Despite of a dramatic improvement of neuroimaging methods and refinements of
operative techniques mortality of up to 13% is still reported
in contemporary literature and recurrence rates between 0 to 76% (1)..
purpose of this paper is to present a new method of surgical treatment
of Chronic subdural hematomas (CSDHs) that in our opinion reduces
recurrences and provides rapid re-expansion of the brain.
Materials and Methods:
the last two years we operated
157 cases of CSHs , in 9
patients we performed trephine
craniotomy with cisternal drainage ..There were
7 men and 2 women who ranged in age from 53 to 80 years
(mean 66.5 years).
criteria comprised the following: 1) Solid clod found at surgery; 2) Thick
membranes; 3) multiple loculations of hematoma demonstrated on CT Scan or MRI.
criteria were acute subdural
hematomas, liquid clot , single and fine membrane, small subdural hematoma.
patients underwent assessment using the Rankin daily living scale. The follow up
period ranged from 15 to78 months (mean 34.2 months).
temporal and subtemporal base of
the brain haematomas we use a “Tic” craniotomy of Drake
with a linear incision in front of the tragus . then we performed a total
membranectomy and evacuation of haematoma with opening of the cisterna ambiens.
frontal and fronto-basal haematomas we performed a trephine center
in the supraorbital region , like the supraorbital
key- hole of Scoville. We then open the chiasmatic cistern
after total membranectomy.
fronto- temporal hematomas we performed a mini-pterional trephine craniotomy
with opening of the Silvian
parietal haematomas we perform a trephine center in the parietal region
eminentia parietalis and open the posterior end of the Sylvian fissure (fig.1).
73 year-old man presented with a 15 days history of progressive right side body
weakness and aphasia.
CT Scan showed a left hemispheric suddural haematoma with thick membrane
a multiple loculations (Fig.4). We
performed a left supraorbital approach with membranectomy
cysternal drainage (fig.1.2.3). The motor deficit
and afasia resolved completely in the early
postoperative period. Ten days after the surgery the CT Scan showed complete
resolution of the lesion and adequate expansion on the brain (Fig.5-6) .
were excellent in eight patients , good in one
patient. This patient complicated
with a subdural empiema
and was cure with antibiotics an surgical drainage. He was contaminated by the subdural
drain probably. Postoperative Computerized tomography obtained 7 days
after surgery in all
patients demonstrated total evacuation and adequate expansion of the brain.
CSDH has been recognized as an entity at least since the description recorded by
Virchow in 1857. Later Trotter put forward the theory of trauma to the bridging
veins as a cause of what he named “ subdural haemorrhagic cyst”. Since then
trauma has been recognised as an important factor in the development of CSDH.
of the existing controversy revolves around which technique is optimal for
evacuation of a CSDH.
has been effectively dismissed as an essential component of an operative
procedure for CSDH (7). Therefore, haematoma itself is the promoter for its chronicity,
and removal of haematoma fluid should suffice as the primary goal of surgery. But
we think that removal of thick membranes help to reduce rapidly the mass effect
on brain and give space to approach the basal cisterns. Weigel
reviewed the contemporary literature about chronic subdural
haematomas and conclude that: twist drill craniotomy and burr hole craniostomy
are the safest procedures. Burr hole craniostomy
and craniotomy are the most effective procedures. Drainage reduces the
recurrences rate in burr hole craniotomy especially if
its position is frontal (8) .Burr hole craniostomy
is more effective in treatment recurrence than twist drill craniotomy.
Craniotomy should be considered as the treatment of last choice. Craniotomy is
still the surgical procedure with the least risk
of recurrence (10,11).
on CSDH in1981, relegated craniotomy only for the following: 1) Subdural
reacumulation;2) Failure of the brain to expand
3) removal of solid clot (3).
of the haematoma is the most common postoperative problem. Residual fluid can be
detected on computed tomography in as many of 80% of patients, a majority of
them asymptomatic and clinically insignificant. Symptomatic recurrence has been
noted in 8-37% of postoperative patients. It is more common in the elderly and
inadequate expansion of the brain following the evacuation of the haematoma is
thought to play a part (5).
think that trephine and cisternal
drainage should be use primarily or
as initial procedure when there are
thick membranes, multiple membranes and loculations (6), subacute
lesions with a preponderance of acute blood are also likely to be best served by
trephine craniotomy detected in computed tomography or MRI (9). And
when at surgery the
surgeon notes that
there is insufficient haematoma
drain age through a burr hole because of sizable clots encounter on irrigation
method provides rapid expansion of
the brain because removal of solid clots and thick subdural membranes that press
the brain contralateraly , and also by opening
the arachnoid cisterns admixture the
CSF with residual blood may
encourage absorption and re-establish CSF
circulation through brain convexity making the brain to expand
rapidly ,as seen in our patients. It resembles the expansion of a
deflated balloon when someone
makes an opening in the balloon wall and rapidly recovers its original shape.
This is what we call the balloon effect.(4).
seems that trephine craniotomy and cisternal
drainage give the best clinical and radiologic
results in chronic subdural haematomas
specially if it is applied primarily in haematomas with solid clots ,
thick membranes with multiple loculations.
It is time for a well
designed and adequately sized clinical trial of the treatment of chronic subdural
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Schematic drawing showing
different approaches used in our patients.
Mini-pterional approach, B: Subtemporal
“Tic” Craniotomy, C: Parietal trephine craniotomy.
2: Trephine mini-pterional craniotomy and membranectomy.
Subfrontal approach and draining of
the left chiasmatic cistern.
CT scan with thick membranes and multiple loculations.
Postoperative CT scan demonstrates complete resolution of the lesion.
Patient ten days after the operation.
BORIS ZURITA CUEVA - Neurocirujano
Clínica Alcívar. Chimborazo 3310 y Cañar. Torre Médica No. 3. Piso 7 Oficina
2446097 2333275 Metro:
2563500 Celular: 099950037