Original Article

Craniotomy for encapsulated chronic

subdural haematoma
Mumtaz Ali, Zahid Khan, Seema Sharafat, Khalid Mahmood Khan
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)

Introduction
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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The initial surgical management of chronic subdural haematoma (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 Craniotomy 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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CRANIOTOMY FOR ENCAPSULATED CHRONIC SUBDURAL HAEMATOMA Ali, et al

membranectomy in patients with repeated recurrent haematoma 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 haematoma, multiseptal, partially calcified membrane and recurrent haematoma for more than two times were included in
this study. Paediatric haematoma, thin non-enhancing membrane, 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. Computerized 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 underwent 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 pneumocephaly. 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

VOLUME 15, NO. 2, OCTOBER 2011

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 enlargement.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 craniectomy 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 different 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 irrigation 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 haematoma 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 membranectomy 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 6year 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 intracerebral 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.

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Aoki N, Masuzawa H: Bilateral chronic subdural hematomas

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