British Journal of Neurosurgery, December 2009; 23(6): 612–616

ORIGINAL ARTICLE

Chronic subdural hematoma—Craniotomy versus burr hole trepanation

YVONNE MONDORF, M.D.1, MUAATH ABU-OWAIMER, M.D.1, MICHAEL R. GAAB,

M.D., PH.D.1, JOACHIM M. K. OERTEL, M.D., PH.D.2
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14

1
Department of Neurosurgery, Hannover Nordstadt Hospital, Klinikum Hannover, 30167 Hannover and 2Department of
Neurosurgery, Johannes-Gutenberg-University, 55131 Mainz, Germany

Abstract
The authors present a series of more than 200 surgical procedures for chronic subdural hematoma in a 5-year-period.
Clinical presentation and neurosurgical treatment were regarded with a special focus on the surgical technique. Between
March 2003 and July 2008, 193 patients (113 male and 80 female, mean age 72.5 yrs [range 26–97 yrs]) suffering from
chronic subdural hematoma were retrospectively analyzed. One-hundred-fifty-one craniotomies and 42 burr holes were
performed. Forty-two craniotomy patients (27.8%) in contrast to 6 burr hole patients (14.3%) required surgical revision. A
craniectomy was performed as an ultima ratio after at least 2 prior evacuations in 3 cases. Chronic subdural hematoma is a
disease of the elderly. A craniotomy seems to possess a higher rate of recurrence of the chronic subdural hematoma so that a
burr hole evacuation should be preferred. Craniectomy might be a good therapeutic option in complicated recurrent chronic
subdural hematomas.

Key words: Chronic subdural hematoma, craniotomy, burrhole, subdural hygroma.

For personal use only.

Introduction
Chronic subdural hematoma is a common intracra-
nial pathology. Especially elderly people are affected.
The recurrence rate after surgical treatment ranges
from 9.2 to 26.5%.1 Diagnosis and treatment are well
established, but recurrence and complications are
not completely understood.9 The population in
industrial nations is becoming older because of a
good health care system and excellent nutrition.
Many people receive long-term therapy with antic-
oagulants or antiplatelet agents. Thus, the incidence
of chronic subdural hematoma is expected to further
increase.
The genesis of chronic subdural hematoma is not
well known but nevertheless controversially dis-
cussed. In any case, craniocerebral injury plays a
decisive role in the development of chronic subdural
hematoma that can originate from acute subdural
hematoma but as well from subdural hygroma.6,7,8,12
The mechanism which converts subdural hygroma to
chronic subdural hematoma is still under investiga-
tion. Probably neovascularization by fragile vessels
occurs and repetitive tiny hemorrhages subsequently
cause a chronic subdural hematoma.6,14,18 In sub-
dural hematoma cases originating from an acute
subdural hematoma, the usual resorption of coagu-
lated blood failed. Okumura et al. assume 4 different
conditions that contribute to a transformation of an
acute to a chronic subdural hematoma. The trans-
formation could happen in elder patients, in patients
with a history of brain atrophy, in patients with an
expansive-type image of acute subdural hematoma in
computed tomography and cerebrospinal fluid mix-
ing in the hematoma shown in the acute-phase
tomography.12
Numerous treatment options do exist for the
chronic subdural hematoma. The optimal neurosur-
gical treatment is not well defined in the current
literature. Burr hole craniotomy, trepanation and
twist drill craniotomy with and without irrigation are
performed in chronic subdural hematoma, the
placement of a subdural drainage is not consis-
tent.3,5,10,11,16,19 Chronic subdural hematomas
might present themselves clinically with headache,
behavioural disturbance, paresis and seizure. In some
patients seizures occur after surgery although the
incidence of seizures in patients undergoing burr-
hole intervention with a closed-system drainage for
chronic subdural hematoma is low.2
Here, the authors present their series of 193
patients suffering from chronic subdural hematoma
treated surgically in a 5-year interval. Different

Correspondence: Dr. Joachim M. K. Oertel, Neurochirurgische Klinik und Poliklinik, Universitätsmedizin, Johannes-Gutenberg-Universität,
Langenbeckstrasse 1, 55131 Mainz, Germany. Tel./Fax: þ49-6131-17-3734/-6418. E-mail: oertelj@freenet.de

Received for publication 4 May 2009. Accepted 23 September 2009.

ISSN 0268-8697 print/ISSN 1360-046X online ª The Neurosurgical Foundation
DOI: 10.3109/02688690903370297
 Craniotomy versus burr hole for subdural hematoma 613

surgical strategies as well as the pre- and post-
operative clinical outcome are evaluated.
Material and methods
Study design
Between March 2003 and July 2008, 193 patients
were treated surgically because of a chronic subdural
hematoma at the Department of Neurosurgery of the
Nordstadtkrankenhaus Hannover (Fig. 1a). All
patients were analyzed retrospectively concerning
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14
sidered as risk factors. All patients or their relatives
were interviewed for history of head trauma. The
interval between the trauma and the first incidence of
clinical symptoms concerning the chronic subdural
hematoma was also determined. As a satisfactory
result was considered if there was no or only small
no-space-occupying residual hematoma. Addition-
ally, the patients clinical outcome was regarded
whether they were discharged home, to a rehabilita-
tion clinic, another specialist department or to a
nursing home.

preoperative clinical appearance and preoperatively

computed tomography. Both postoperative clinical
outcome and postoperative computed tomography
were evaluated. The principal clinical symptoms
regarded in this study were headache, decreased
consciousness, paresis, aphasia, disorientation and
occurrence of seizures. In addition, age and sex
distribution as well as the side of the hematoma were
investigated.
A therapy with anticoagulants or antiplatelet
agents, coagulopathy and alcohol abuse were con-
For personal use only.
Surgical technique for the treatment of chronic subdural
hematoma
In 151 patients, the approach was done via a small
osteoplastic craniotomy and in 42 patients via a
burr hole trepanation. After dural incision, the
outer membrane of the chronic hematoma was
coagulated and opened. After evacuation of the
fluid hematoma a careful irrigation with Ringer’s
solution followed in every operation—until the
irrigation solution remained clear. In any case,

FIG. 1. (a) Cranial computed tomography of a 65-year-old male presenting a left hemispheric chronic subdural hematoma and slight midline
shift. (b) Postoperative computed tomography of the same patient 3 hours after surgery because of a generalized seizure. (c) Postoperative
computed tomography of the same patient 6 days after surgery. A recurrence of the hematoma is shown with beginning midline shift. The
brain shows no expansion tendency. (d) Postoperative computed tomography of the same patient after craniectomy. (e) Postoperative
computed tomography after reimplantation of the bone. Now the brain presents well extended.
 614 Y. Mondorf et al.
the internal membrane of the hematoma was also
opened. In 190 patients, a subdural drainage with a
low vacuum suction reservoir was placed; no
drainage was placed in 3 cases. Within the first 3
days after surgery, the drainage was removed, and
the skin was closed with an additional single
suture.
Results
A total of 241 surgical procedures in 193 patients
suffering from chronic subdural hematoma were
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14
performed during the evaluation period. One-hun-
dred-fifty-one patients were treated via a craniotomy
and in 42 patients a burr hole was performed. Patient
age comprised 26 to 97 years. The mean age was
72.5 years. One-hundred and thirteen patients (59%)
were male and 80 (41%) were female. The chronic
subdural hematoma was left hemispheric in 90 cases
(47%), right hemispheric in 74 cases (38%) and
bilateral in 29 cases (15%). A therapy with antic-
oagulants or antiplatelet agents was present in 40%
(n ¼ 78), a coagulopathy in 2% (n ¼ 3) and an
alcohol abuse in 6% (n ¼ 11).
For personal use only.
Clinical signs and computed tomography
The most frequent clinical sign was hemiparesis in
112 patients (58 %), followed by decreased con-
sciousness in 70 (36.3%) and aphasia in 46 (23.8%).
In 100% (n ¼ 193) of the patients, a space occupying
uni- or bilateral chronic subdural hematoma was
found in the computed tomography of the head
correlating to clinical signs. A decision for surgical
intervention was taken. After surgery, symptoms
improved or disappeared completely in 68.9%
(n ¼ 104), remained unchanged or became even
worse in 31.1% (n ¼ 47) in the patients group treated
with a craniotomy. Symptoms improved or disap-
peared completely in 85.7% (n ¼ 36), remained
unchanged or became even worse in 14.3% (n ¼ 6)
in the patients group treated with a burr hole
drainage. A satisfactory postoperative computed
tomography result was found in 77.7% (n ¼ 150),
whereas a space occupying residual hematoma or
rebleeding was seen in 24.9 % (n ¼ 48, Fig. 1b, c).
The recurrence rate was 27.8% (42 cases) in patients
treated with craniotomy and drainage and 14.3% (6
cases) in patients treated with a burr hole drainage.
Seizures were observed in 15 patients (6.7%) pre-
operatively and in 14 patients (7.3%) postoperatively.
History of head trauma
One-hundred-thirty-seven patients or their relatives
(70%) remembered a head trauma. The shortest
interval between the injury and the appearance of
clinical signs due to the chronic subdural haematoma
was 1 day, the longest interval was 230 days, and the
mean interval scored 37.3 days.
Surgical technique
One-hundred-fifty-one patients (78.2%) were treated
with an osteoplastic craniotomy and a subdural
drainage with a low suction vacuum reservoir.
Forty-two patients (21.8%) were operated on per-
forming a burr hole trepanation and subdural
drainage with a low suction vacuum reservoir except
three procedures (1.6%) without implantation of any
drain. In all procedures, careful irrigation with
Ringer’s solution was done until the solution
remained clear. Three patients (1.6%) underwent a
craniectomy with the placement of a subdural and
subgaleal drainage with low suction reservoir after
repetitive revision surgery. In detail, one 70-year-old
male patient had undergone standard surgery per-
forming a trepanation and subdural drainage place-
ment three times until a craniectomy with subdural
drainage placement was performed. In one 70-year-
old female patient and one 65-year-old male patient,
a craniectomy was performed after the first recur-
rence (Fig. 1a-e). All three patients showed no
expansion tendency of the brain during the opera-
tion. After craniectomy, all 3 patients were dis-
charged to a rehabilitation clinic and recovered
completely. In both male patients, the bone was
reimplanted. No problems occurred, and the brain
showed a very good expansion without new subdural
hematoma.
Recovering of the patients
Seventy-nine patients (52.3%) treated with a cra-
niotomy and subdural drainage and 27 patients
(64.3%) treated with a burr hole drainage were
discharged home and able to care for themselves.
Sixteen (8.6%) of all cases were discharged to
another specialist department for the treatment of
another accompanying disease. Eight patients (5.3%)
treated with crainiotomy and 3 patients (7.2%)
treated with a burr hole were discharged to nursing
home either because they lived there before surgery
or they had a poor recovering tendency despite of
evacuation of the chronic subdural hematoma. Seven
patients (4.6%) of the craniotomy group and one
patient (2.4%) of the burr hole group died after
surgery within the hospital stay. They all died
because of their internal diseases not directly related
to the chronic subdural hematoma.
Discussion
Chronic subdural hematoma is an increasing disease
in developed countries. The incidence of chronic
subdural hematoma due to craniocerebral injury
represents a relevant portion of daily neurosurgical
practice. Especially elderly people are affected. The
mechanism leading to chronic subdural hematoma is
not well known. Chronic subdural hematoma,
subdural hygroma and acute subdural hematoma
 Craniotomy versus burr hole for subdural hematoma
usually occur in the subdural space after trauma.8
The existence of an acute subdural hematoma or
subdural hygroma is the predisposition for the
development of a chronic subdural hematoma. Lee
et al. evaluated 436 patients and they found that the
origin for chronic subdural hematoma was a subdural
hygroma in up to half of the cases.8 In subdural
hygroma, the neomembrane produced by dural
border cells in unresolved hygroma is vascularized
with fragile vessels and repeated bleedings lead to
chronic subdural hematoma.6,13,18 Tokmak et al.
regard the chronic subdural hematoma as a local
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14
inflammatory process that causes the development of
granulation tissues regarded as the outer membrane
of the hematoma. Exudation of capillaries of
this membrane leads to an enlargement of the
hematoma.17
In the present study, the mean age of the patients
suffering from chronic subdural hematoma scored
72.5 years. There was a male predominance of
almost 60%. Forty percent were on anticoagulants
or antiplatelet agents. One-hundred and thirty-seven
patients had a history of head trauma (71%). Fifty-
five percent of the patients were successfully treated
and discharged home without neurological deficit.
Thus, chronic subdural hematoma is a disease of the
For personal use only.
elder population. Although it can be treated success-
fully and the majority of patients are discharged
home without deficit, some peculiar findings have to
be discussed.
The mean age in the current study scored 72.5
years, 59% were male. This corresponds to earlier
studies published. Muzii et al. found a mean age of
78.7 years in a study with 47 cases, and Gelabert-
González et al. evaluated a mean age of 72.7 years.4,10
Gelabert-Gonzáles et al. retrospectively analyzed
1000 patients suffering from chronic subdural hae-
matoma and included 682 males and 372 females,
and Mori et al. included 500 Patients with 359 males
and 141 females.4,9 Thus, the chronic subdural
hematoma can be considered to be a disease of the
seventh decade of life predominating in male patients.
In the current study, seizures occurred preopera-
tively in 6.7% and postoperatively in 7.3% of the
patients. They were all treated with anticonvulsants.
Chen et al. correlated preoperative computed tomo-
graphic appearance of chronic subdural hematoma
with the need of postoperative seizure prophylaxis
and concluded that the postoperative seizure rate
appeared high in the group with mixed density type
lesions on computed tomography and in those with
left unilateral chronic subdural hematoma.2 The
authors of the present study have not found any
correlation between seizure incidence and computed
tomography findings. However, this could be a topic
for further prospective studies.
Various surgical strategies for chronic subdural
hematoma have been advocated. The optimal treat-
ment is not well defined. In the present case series,
the approach was done via a burr hole trepanation or
615
via an osteoplastic craniotomy. In 98.4% of all cases,
a subdural drainage with a low suction vacuum
reservoir was placed after careful irrigation. The
recurrence rate was different between both groups.
The recurrence rate in the craniotomy group was
27.8% and the recurrence rate in the burr hole group
was 14.3%. Mori et al. treated 500 patients with a
burr hole craniotomy and a vacuum system drainage.
They observed a good recovery in 89.4% and a
hematoma recurrence in 9.8%.9
Muzii et al. found a similar recurrence rate,
mortality and neurological recovery in a series of 47
patients. Twenty-two of them underwent twist drill
craniotomy, and 24 patients underwent burr hole
craniotomy with subdural irrigation. Both groups
received closed-system drainage and a suction re-
servoir.10 Santarius et al. randomised 215 patients
with chronic subdural hematomas assigned to drain
or no drain groups. They found that the use of drain
with burr hole drainage is associated with lower
recurrence rate, better neurological status at dis-
charge, and lower mortality 6 months.15 This study
gave evidence for the commonly accepted strategy of
drain placement as for example by the authors of the
present study.
Additionally, irrigation of the subdural space is
controversially discussed. Zakaraia et al. compared 42
patients treated with burr hole craniotomy without
irrigation and drainage to 40 patients with irrigation
and drainage, they found no differences in the good
outcome between both groups and had a recurrence
rate of 12.2%.19 Gurelik et al. compared 42 patients
treated with burr hole irrigation to 38 patients with
burr hole drainage without irrigation concerning the
recurrence rate and found no difference between both
groups.5 Okada et al. regarded the postoperative
hospitalization in 40 patients, 20 of them were treated
by burr hole irrigation and the other 20 patients were
treated by burr hole drainage.
They found a postoperative hospitalization of 14.1
days in the drainage group and 25.5 days in the
irrigation group. Furthermore they had only one
recurrence in the drainage group and five cases in the
irrigation group.11 Stanisic et al. evaluated the post-
operative recurrence rate related to anamnestic,
clinical, surgical and neuroradiological imaging vari-
ables in 99 patients treated with burr hole craniost-
omy. The postoperative recurrence rate was 14.9%.16
In the current series of chronic subdural hematoma,
the success rate as defined of discharge at home with
the symptom-free recovery also differed in both
groups.
A success rate of 52.3% was found in the
craniotomy group and a success rate of 64.3% was
found in the burr hole group. These results are
inferior to the results published. However, the
authors think that some peculiar prerequisites have
to be considered. First, only patients returning home
caring for themselves were considered as a successful
treatment. Thus, all patients admitted from a nursing
 616 Y. Mondorf et al.
home being severely disabled were not suitable per se
for a successful treatment. Additionally, the indica-
tion for revision surgery was made based on clinical
presentation but as well on the appearance of the
hematoma in postoperative computed tomography
scans. Even in good clinical conditions, a revision
surgery was recommended when a significant space
occupying effect on the postoperative computed
tomography scan was seen. Taking these conditions
into account, the results of the present study most
likely are comparable to other larger series although a
more thorough prospective evaluation should be
Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/25/14
performed in the near future.
Finally, 3 patients of this series underwent
craniectomy because of a recurrence of the chronic
subdural hematoma. This procedure is not yet
described in literature very often. It might represent
a therapeutical option in the recurrence of chronic
subdural hematoma, especially when the brain does
not show any expansion tendency during surgery.
In all, chronic subdural hematoma is a common
disease that is very frequent in the elderly population.
There is a predominance of male gender. Antic-
oagulants and antiplatelet coagulation medication
probably significantly contributes to the increased
frequency of chronic subdural hematoma. While the
For personal use only.
optimal surgical strategy is still under debate, burr
hole trepanation should be favored. Osteoclastic
craniectomy might represent a good surgical option
in persistent subdural hematoma.
Conclusion
The present study reports the clinical presentation,
surgical technique and outcome of chronic subdural
hematoma treated at a single institution in a 5-year
period. A history of head trauma was found in 71%
with a mean interval between trauma and clinical
symptoms of 37 days. Anticoagulants or antiplatelet
coagulation therapy was present in 40%. The most
frequent preoperative symptom was hemiparesis with
58%. Surgery was successfully performed in 75% of
the patients. Twenty-five percent received revision
surgery with 3 (1.6%) undergoing craniectomy as a
second revision. All 3 patients recovered. The
recurrence rate and the recovery rate were different
in both groups. The recurrence rate was nearly twice
the number in the patients group treated with a
craniectomy. In all, chronic subdural hematoma is a
common disease very frequent in the elderly popula-
tion predominantly affecting male patients. Burr hole
trepanation evacuation seems to lead to superior
results. In complicated recurrent cases, osteoclastic
craniectomy might represent a surgical option.
Declaration of interest: The authors gratefully
acknowledge Dr. F.M. Oertel’s support in the
preparation of the manuscript. This study was not
supported. The authors have nothing to disclose. Y.
Mondorf and M. Abu-Owaimer were responsible for
data collection. J. Oertel initiated the study and wrote
most of the paper including the interpretation of the
data. M. Gaab was involved in data collection and
revision of the preliminary manuscript.
References
1 Abouzari M, Rashidi A, Rezaii J, et al. The role of postoperative
patient posture in the recurrence of traumatic chronic sub-
dural hematoma after burr-hole surgery. Neurosurgery 2007;61:
794–7.
2 Chen CW, Kuo JR, Lin HJ, et al. Early post-operative seizures
after burr-hole drainage for chronic subdural hematoma:
correlation with brain CT findings. J Clin Neurosci 2004;11:
706–9.
3 Erol FS, Topsakal C, Faik Ozveren M, et al. Irrigation vs.
closed drainage in the treatment of chronic subdural hematoma.
J Clin Neurosci 2005;12:261–3.
4 Gelabert-González M, Iglesias-Pais M, Garcı́a-Allut A, et al.
Chronic subdural haematoma: surgical treatment and outcome
in 1000 cases. Clin Neurol Neurosurg 2005;107:223–9.
5 Gurelik M, Aslan A, Gurelik B, et al. A safe and effective
method for treatment of chronic subdural haematoma. Can J
Neurol Sci 2007;34:84–7.
6 Lee KS. Natural history of chronic subdural haematoma. Brain
Inj 2004;18:351–8.
7 Lee KS, Bae WK, Yoon SM, et al. Location of the chronic
subdural haematoma: role of the gravity and cranial morpho-
logy. Brain Inj 2001;15:47–52.
8 Lee KS, Doh JW, Bae HG, et al. Relations among traumatic
subdural lesions. J Korean Med Sci 1996;11:55–63.
9 Mori K, Maeda M. Surgical treatment of chronic subdural
hematoma in 500 consecutive cases: clinical characteristics,
surgical outcome, complications, and recurrence rate. Neurol
Med Chir 2001;41:371–81.
10 Muzii VF, Bistazzoni S, Zalaffi A, et al. Chronic subdural
hematoma: comparison of two surgical techniques. Preliminary
results of a prospective randomized study. J Neurosurg Sci
2005;49:41–6.
11 Okada Y, Akai T, Okamoto K, et al. A comparative study of the
treatment of chronic subdural hematoma—burr hole drainage
versus burr hole irrigation. Surg Neurol 2002;57:405–9.
12 Okumura Y, Shimomura T, Park YS. A study of acute
subdural hematoma developing into hematoma with capsule
formation. No Shinkei Geka 1998;26:691–8 (Jpn).
13 Park SH, Lee SH, Park J, et al. Chronic subdural hematoma
preceded by traumatic subdural hygroma. J Clin Neurosi
2008;15:868–72.
14 Reina MA, López Garcı́a A, de Andrés JA, et al. Does the
subdural space exist? Rev Esp Anestesiol Reanim 1998;45:367–76.
15 Santarius T, Kirkpatrick PJ, Ganesan D, et al. Randomised
controlled trial of the use of drains versus no drains after burr
hole evacuation of chronic subdural haematoma. P 125-126 in:
Proceedings of the 153rd Meeting of the Society of British
Neurological Surgeons: Oral Abstracts of the Platform
Presentations’, Br J Neurosurg 2009;23:111–35.
16 Stanisic M, Lund-Johansen M, Mahesparan R. Treatment of
chronic subdural hematoma by burr-hole craniostomy in
adults: influence of some factors on postoperative recurrence.
Acta Neurochir 2005;147:1249–256.
17 Tokmak M, Iplikcioglu AC, Bek S, et al. The role of
exudation in chronic subdural hematomas. J Neurosurg 2007;
107:290–95.
18 Yamashima T. The inner membrane of chronic subdural
hematomas: pathology and pathophysiology. Neurosurg Clin N
Am 2000;11:413–24.
19 Zakaraia AM, Adnan JS, Haspani MS, et al. Outcome of 2
different types of operative techniques practiced for chronic
subdural hematoma in Malaysia: an analysis. Surg Neurol
2008;69:608–15.