Mumtaz Ali, Zahid Khan, Seema Sharafat, Khalid Mahmood Khan

Craniotomy for encapsulated chronic subdural haematoma

Introduction The initial surgical management of chronic subdural haema-toma (CSDH) is still controversial and a standard therapy does not exist.1,5,6 Numerous surgical treatments have been proposed.2,6,10 Though simple burr hole evacuation and irrigation of subdural space has become accepted but with considerable rates of recurrence (2.7 - 37%).4-6,9 Cranio-tomy with membranectomy is recommended in patients with thicker haematoma membrane, thick haematoma fluid with a lot of sludge, multiseptaded or loculated haematoma or partially calcified haematoma membrane.8 In the present study surgical outcome of craniotomy and

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Original Article

Abstract Objectives: A descriptive analytical study to assess the surgical outcome of craniotomy for encapsulated chronic subdural haematoma (CSDH) in our department. A total of 16 patients with CSDH were operated with craniotomy and membranectomy. The study duration was 11 years, from July 1998 - June 2009. Material and methods Inclusion criteria: Adult patients of both genders with CSDH having: 1. Repeated recurrence after burr hole craniotomy. 2. Partially or completely calcified membrane around CSDH. 3. Loculated haematoma. 4. Enhanced membrane haematoma. 5. Haematoma with thick membrane. Exclusion criteria: Patients having CSDH with: 1. Paediatric age group. 2. Liquefied haematoma. 3. Initial surgery for haematoma. 4. Patients with bleeding disorders. Patients clinical details were documented after admission and radiological assessment was done. Selected cases after team discussion were subjected to this procedure after explaining prognosis to the relatives. Results: A total of 332 cases with CSDH were operated during a period of 11 years, out of which 16 patients underwent craniotomy and membranectomy, making 4.8% of the total; 14 males and 2 females with 7:1 ratio, having median age of 55.5 years (age range from 38 - 73 years) were included. Cause of haematoma was RTA in 9 cases; fall in 3 cases while in 4 cases we could not find the cause. Eleven patients had already been operated by two burr hole while 5 cases were reported as fresh cases. Calcified membrane was noted in 4, thick membrane with straw coloured sludge in 12 cases. Seizures were noted in 3 cases. One patient died due to acute intracerebral bleed. Conclusion: Craniotomy and membranectomy gives good results in selected patients suffering from CSDH. One should individualize the procedure by considering different clinical and radiological features. Key words: Extended craniotomy, membranectomy and encapsulated subdural haematoma. (p12-14)

Department of Neurosurgery Postgraduate Medical Institute Govt Lady Reading Hospital Peshawar Pakistan Correspondence: Dr. Mumtaz Ali Department of Neurosurgery Postgraduate Medical Institute Govt Lady Reading Hospital Peshawar Pakistan Email:ns_mumtazali@yahoo.com

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CRANIOTOMY FOR ENCAPSULATED CHRONIC SUBDURAL HAEMATOMA Ali, et al

membranectomy in patients with repeated recurrent haema-toma after initial burr hole craniostomy is considered. Material and methods From July 1998 - June 2009, 16 cases with CSDH who did not improve with burr hole evacuation were included in this study. These patients received surgical treatment in our department which is a tertiary care department for the people of NWFP and those near the Afghan border. There were 14 males and 2 females, with male/female ratio of 7:1, mean age was 55.5 years with a range of 38 - 73 years. Patients with thick capsular haematoma, enhanced haema-toma, multiseptal, partially calcified membrane and recur-rent haematoma for more than two times were included in this study. Paediatric haematoma, thin non-enhancing mem-brane, bilateral CSDH and patients with bleeding disorder were excluded from this study. All patients were admitted with proper record of clinical features, radiological finding and lab investigation. Com-puterized tomography brain was the main diagnostic tool in all cases, MRI brain was done in 3 cases while keeping the clinical and radiological picture in mind, craniotomy was planned. Patients were kept in ICU until satisfactory recovery and later on were sent home. Follow-up visits were made after 4 and 8 weeks. Postoperative status and related complications were documented. Results During these 11 years of our study we operated 332 patients with CSDH. Of these 332 cases, 16 (4.8%) patients under-went craniotomy and membranectomy. There were 14 males and 2 females with male/female ratio of 7:1, respectively. Their age ranged from 38 - 73 years with median age of 55.5 years. Cause of haematoma was minor head injury due to fall and RTA in 12 cases while in 4 cases we could not find the cause. There were no patients with bleeding disorder; using anticoagulants or with history of alcoholism. Age related brain atrophy was noted in 5 cases, 11 cases had history of two burr hole craniectomy; two times in 7 cases and 3 times in 4 cases. Two patients with recurrence were also having evidence of mild pneumo-cephaly. Bony calcified membrane was noted in one case and partially calcified in 3 cases. Thick membrane with straw coloured sludge and debris was found in 12 cases. Postop seizure was noted in 3 cases; they responded well to anticonvulsant treatment. Basal ganglion bleed was found in one case. One patient died due to intracerebral bleed. No patient developed wound infection or recurrence. Discussion Chronic subdural haematoma is a dural inflammatory disease also called pachymeningitis haemorrhagic interna. It initiates as a local inflammatory process of the dura matter

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due to external stimulus such as CSF, blood, or blood products. The mesenchymal cells of the inner dural layer proliferate and form an inflammatory capsule or membrane which is the outer membrane of haematoma and is a kind of granulation tissue containing inflammatory cells, immature vessels and connective fibres. The inner membrane of haematoma consists of collagen fibres and less number of vascular structure. Thus, the outer membrane has gap junction like microcapillary and absent or incomplete basement membrane which causes exudation of intravascular contents. Growth factors appear in the outer membrane which is responsible for neovascularisation and vascular proliferation. The growth control of CSDH is proportional to the thickness of the layer of the macrocapillaries. This exudation from macrocapillaries in the outer membrane of CSDH may play an important role in lesion enlarge-ment.4,7,12,13 Different surgical procedures can be adopted for evacuation of the haematoma keeping in mind the age, size, cause and CT finding of CSDH. These procedures include simple twist craniostomy, single burr hole craniec-tomy with or without closed drainage system, two burr hole craniectomy, and extended craniotomy and membranectomy. The selection of these procedures varies from patient to patient and is individualized accordingly considering differ-ent variable factors in patients and working environment.4 A definite standard therapy does not yet exist but for the initial treatment of CSDH, burr hole drainage with irriga-tion of haematoma cavity with or without closed drainage system is recommended. It is safe and time saving. Keeping the recurrence rate (2.7 - 37%), CT appearance of haema-toma and medical condition of patient in mind, extended craniotomy with membranectomy is recommended in limited number of patients. This procedure is individualized from patient to patient but in majority of cases is recommended for instances of organised haematoma, with rebleeding, thicker or enhancing membrane and repeated recurrent haematoma.3,4,11 We operated 16 cases for extended craniotomy and mem-branectomy in a duration of 11 years, in which gross excision of thickened space occupying haematoma membrane was performed. Jin Yal Lee et al, operated 13 cases out of 172 patients with CSDH during a 4-year period between 1996 - 2000.4 Firsching R et al, operated 37 cases out of 103 patients with CSDH with encapsulated SDH during a 6-year period.11 Out of 243 cases of CSDH, 14 patients with organised haematoma were operated by Rocchi in a 9-year period. The mean age period in our series of patients was 55.5; relatively younger than 63 years of Fisching et al, and 60 years of Jin Yal Lee et al. The reason for our younger age is increased incidence of RTA and short average life span.4,11 Our society is male dominant and men are more exposed to

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CRANIOTOMY FOR ENCAPSULATED CHRONIC SUBDURAL HAEMATOMA Ali, et al

accident and physical assault as compared to female (7:1). Our case is not comparable with western society cases where the ratio is equal or slightly more dominant by the female gender. We consider the indication in our cases keeping the CT status and recurrence rate of CSDH after burr-hole evacuation in mind. In 3 of our cases the membrane was partially calcified not allowing brain to expand, while in one patient it was bony hard. In the remaining 12 cases, thick sludge and thickened membrane was excised. Neither recurrence nor infection was seen in any of our patients. In 9 cases, the previous burr holes were converted into craniotomy flap by adding another two burr holes, while in 7 cases designed osteoplastic bone flap were made. Three patients developed seizures. In 10 patients complete membrane was removed and in the remaining 6 cases membrane was partially excised. Mortality was seen in one patient due to reactive intracere-bral haemorrhage in capsular area, which was re-operated without any improvement. Conclusion Craniotomy and membranectomy gives good results in selected patients suffering from CSDH. One should individualize the procedure by considering different clinical and radiological features. References 1. Aoki N, Masuzawa H: Bilateral chronic subdural hematomas

without communication between the hematoma cavities: treat-ment with unilateral subdural peritoneal shunt. Neurosurgery 1988, 22(5): 911-3.

2. Ernestus RI, Beldzinski P, Lanfermann H, Klug N: Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 1997, 48(3): 220-5.

3. Firsching R, Frowein RA, Thun F: Encapsulated subdural hematoma. Neurosurg Rev 1989, 12(Suppl 1): 207-14.

4. Gurunathan J: Treatment of chronic subdural hematoma with burr hole craniostomy and irrigation. Ind J Neurotrauma 2005, 2: 127-30.

5. Laumer R, Schramm J, Leykauf K: Implantation of a reservoir for recurrent subdural hematoma drainage. Neurosurgery 1989, 25(6): 991-6.

6. Lee JY, Ebel H, Ernestus RI, Klug N: Various surgical treatments of chronic subdural haematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol 2004, 61(6): 523-7; Discussion 527-8.

7. Lee KS: Natural history of chronic subdural hematoma. Brain Inj 2004, 18(4): 351-8.

8. Mohamed EE: Chronic subdural hematoma treated by craniotomy, durectomy, outer membranectomy and subgaleal suction drainage. Personal experience in 39 patients. Br J Neurosurg 2003, 17(3): 244-7.

9. Probst C: Peritoneal drainage of chronic subdural hematoma in older patients. J Neurosurg 1988, 68(6): 908-11.

10. Suzuki K, Sugita K, Akai T, Takahata T, Sonobe M, Takahashi S: Treatment of chronic subdural hematoma by closed-system drainage without irrigation. Surg Neurol 1998, 50(3): 231-4.

11. Svien HJ, Gelety JE: On the surgical management of encapsu-lated subdural hematoma. A comparison of the results of membranectomy and simple evacuation. J Neurosurg 1964, 21: 172-7.

12. Tokmak M, Iplikcioglu AC, Bek S, Gkduman CA, Erdal M: The role of exudation in chronic subdual hematomas. J Neurosurg 2007, 107(2): 290-95.

13. Yamashima T, Yamamoto S, Friede RL: The role of endothelial gap junctions in the enlargement of chronic subdural hematomas. J Neurosurg 1983, 59(2): 298-303.

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