Hindawi

Computational Intelligence and Neuroscience

Volume 2022, Article ID 2823314, 5 pages
https://doi.org/10.1155/2022/2823314

Research Article
Surgical Treatment of Bilateral Chronic Subdural Hematoma

Yan Zhuang , Ming Jiang, Jiahao Zhou, Jun Liu, Zhen Fang, and Zejun Chen
Department of Neurosurgery, The Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang 212001,
Jiangsu Province, China

Correspondence should be addressed to Zejun Chen; 1000011430@ujs.edu.cn

Received 21 April 2022; Revised 20 May 2022; Accepted 24 May 2022; Published 27 June 2022

Academic Editor: Muhammad Zubair Asghar

Copyright © 2022 Yan Zhuang et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Chronic subdural hematoma (CSDH) is one of the common clinical intracranial hemorrhagic disorders, accounting
for 16%–20% of bilateral CSDH. At present, the surgical treatment of bilateral CSDH mainly includes drilling drainage and
neuroendoscopic assistance. The main objective of this paper was to compare the effects of two surgical methods on CSDH.
Methods. 153 patients who were diagnosed with CSDH were included in this study. 79 patients were treated with bilateral drilling
drainage, and the other 74 patients were treated with neuroendoscope-assisted drainage. The clinical data of the two groups were
compared, and the surgical indexes, neurological function, cure rate, and recurrence rate of the two groups were compared. The
operation indexes of patients include operation time, postoperative hematoma volume, hospital stay, extubation time, mis-
placement of drainage tube, recurrence, and hematoma clearance rate. Results. All patients underwent CT examination one day
after operation. The CT imaging detection of the two groups was generally good. The cranial CT was reexamined before discharge.
The bilateral hematoma disappeared in 114 patients, the unilateral hematoma disappeared in 29 patients, a small amount of
compensatory crescent very low-density shadow subdural effusion was observed on the other side, and a small amount of
compensatory crescent very low-density shadow subdural effusion was observed on both sides in 10 patients. There was no space
occupying effect and intracranial gas disappeared. Compared with neuroendoscopic assisted drainage, the operation time of
drilling drainage patients was significantly shorter. The extubation time, drainage tube dislocation, recurrence rate, postoperative
hematoma volume, and hematoma clearance rate of patients receiving neuroendoscopic assisted drainage were significantly better
than those receiving drilling drainage. The Markwalder score and hospital stay between the two groups were not significant.
Conclusions. Drilling drainage and neuroendoscopic assisted surgery have good therapeutic effects on bilateral CSDH. The
operation time of drilling drainage is shorter. Neuroendoscopic assisted surgery has more advantages in extubation time,
misplacement of drainage tube, recurrence, postoperative hematoma volume, and hematoma clearance rate.

1. Introduction improved [8, 9]. Neuroendoscopy has the advantages of

CSDH is one of the common intracranial hemorrhagic
disorders [1, 2]. CSDH is common in older adults, mostly
secondary to head trauma [3]. Bilateral subdural hematomas
have the characteristics of severe symptoms, rapid progress,
and easy deterioration and should be treated as soon as
possible [4, 5]. At present, the method of bilateral syn-
chronous drilling, drainage, and flushing is mostly used in
clinic [6, 7]. Drilling drainage has good clinical effect and can
effectively remove hematoma, but there was a certain rate of
catheter misplacement and risk of rebleeding. The removal
of hematoma and postoperative recurrence rate need to be
sufficient light, clear vision, proximity, and multi-angle
observation [10–12]. At present, it is widely used in all as-
pects of neurosurgery. Neuroendoscopic assisted drainage
has been gradually applied to the surgical treatment of
CSDH. However, there is no research to explore the ther-
apeutic effect of drilling drainage and neuroendoscopic
assisted drainage in patients with bilateral CSDH.
In this study, patients with bilateral CSDH were collected
and treated with bilateral drilling drainage or neuro-
endoscope-assisted drainage to explore the therapeutic ef-
fects of the two surgical methods on patients with bilateral
CSDH.
2 Computational Intelligence and Neuroscience
2. Methods
2.1. Patients. A total of 153 patients with bilateral CSDH
were included in this study. There were 89 male patients and
64 female patients. The average age was (60.95 ± 10.26)
years. All patients were clinically diagnosed with bilateral
CSDH. There were 72 cases with definite history of trauma.
The time from trauma to diagnosis of bilateral CSDH was 3
weeks to 3 months. There were 60 cases of hypertension and
43 cases of diabetes mellitus. Among them, 79 patients
underwent bilateral drilling drainage, and 74 patients un-
derwent neuroendoscopic assisted drainage. The neuro-
endoscopy group patients underwent assisted drainage
through neuroendoscopy. The drilling drainage group pa-
tients underwent trans-drilling drainage. The history of
trauma, the history of hematoma, and the amount of he-
matoma between the two groups patients were not signif-
icant (P < 0.05). All patients voluntarily signed the informed
consent form. This study was approved by the ethics review
committee of our hospital.
2.2. Inclusion Criteria. The patients met the diagnostic
criteria of bilateral CSDH. The patients developed symptoms
of chronic intracranial hypertension 3 weeks after trauma or
had no definite history of trauma. Head CT showed bilateral
crescent high, low, or mixed density shadows, with varying
degrees of compression or midline displacement of brain
tissue. MRI showed that T1 and T2 were high signals in the
early stage, and T1 was slightly higher than the low signal
and T2 was high signal in the later stage. Patients can un-
dergo neuroendoscopic surgery or drilling drainage surgery.
2.3. Exclusion Criteria. Exclusion criteria were as follows:
the patient has severe disability and basic diseases and
cannot tolerate general anesthesia and endoscopic surgery;
GCS score <5 or mydriasis (unilateral or bilateral); there is
severe coagulation dysfunction; acute subdural hematoma;
and unilateral CSDH.
2.4. Surgical Methods. Patients in neuroendoscopy group
underwent hematoma removal under rigid neuroendoscopy
under general anesthesia. The patient was in lateral or supine
position, and a 4∼5 cm scalp straight incision was made on
the forehead and temporal part. The mastoid process
spreader was used to open, the skull was drilled, and a bone
flap with a diameter of 2.5∼3 cm was formed with a milling
cutter. After drilling the skull edge, suspend the dura mater,
open the dura mater in the “ten” way, and try not to open the
subdural hematoma capsule. We slowly aspirate part of the
liquefied hematoma with a syringe to slowly reduce the
intracranial pressure. After bipolar electrocoagulation and
electrocautery of the hematoma capsule, cut it off, put a 30°
hard neuroendoscope with a diameter of 4 mm into the
subdural cavity, remove the residual hematoma under the
neuroendoscope, remove the inflammatory capsule of the
hematoma cavity as much as possible, and open the sepa-
ration. After the hematoma is cleared, rinse with normal
saline, place the drainage tube into the subdural cavity under
the direct vision of neuroendoscope, carefully check that
there is no bleeding in the hematoma cavity, and tightly
suture the dura mater after exhausting the air with normal
saline. The bone flap was returned and fixed, and the scalp
was sutured in layers.
The patients in the drilling drainage group underwent
drilling drainage under local anesthesia. In the supine or
lateral position, make a 3∼4 cm scalp straight incision on the
thickest parietal tubercle or forehead of the hematoma, open
the mastoid expander, drill the skull, cut the dura mater and
hematoma capsule, see the dark red bloody liquid gushing
out, place the drainage tube, repeatedly lavage until the
drainage fluid is clear, fix the drainage tube and suture the
wound. Routine symptomatic support treatment was given
after operation. CT was rechecked on the 1st day after
operation and the day before discharge. If the brain tissue
was satisfactory and the midline was well repositioned, the
drainage tube was pulled out.
2.5. Observation Indexes. The surgical indexes, neurological
function, cure, and recurrence of the two groups were
compared. The operation indexes of patients include op-
eration time, hospital stay, extubation time, misplacement of
drainage tube, recurrence, postoperative hematoma volume,
and hematoma clearance rate. Neurological function was
evaluated by Markwalder classification: grade 0: normal
neurological function; grade 1: clear mind, headache, and
dizziness; grade 2: focal neurological dysfunction and dis-
orientation; grade 3: severe neurological dysfunction; grade
4: loss of brain control.
2.6. Statistical Analysis. The data generated in this study
were analyzed by SPSS 26.0 software. Measurement data
are expressed as x ± s, and t-test is performed. The mea-
surement data are expressed as n (%), and the chi-square
test is performed. P < 0.05 indicates a significant
difference.
3. Results
3.1. Comparison of Preoperative Clinical Data in Patients with
Bilateral CSDH. The clinical data of patients in the neu-
roendoscopy group were compared with the patients from
drilling drainage group (Table 1). The gender, age, history
of hypertension, history of diabetes, history of trauma,
midline shift, preoperative hematoma volume, and
Markwalder classification between the two groups were
not significant.
3.2. Postoperative Imaging Findings. All patients were ex-
amined by CT one day after operation. The bilateral hema-
toma cavities of 82 patients were almost closed, the unilateral
hematoma cavities of 57 patients were almost closed, and the
contralateral hematoma cavities decreased significantly. The
hematoma cavity of 14 patients was significantly reduced, and
the CT manifestation of the residual hematoma cavity was
Computational Intelligence and Neuroscience
Table 1: Comparison of general data between the two groups of patients.
Clinical data Neuroendoscopy (n � 74)
Gender (male/female) 40/34
Age (y) 62.83 ± 9.67
History of hypertension 27 (36.49)
Diabetes history 20 (27.03)
History of trauma 32 (43.24)
Midline shift 26 (35.14)
Preoperative hematoma volume (mL) 138.76 ± 20.08
Markwalder 2.43 ± 0.48
crescent low-density shadow under the inner plate of skull.
Five patients had a small amount of intracranial pneumatosis,
and there was no space occupying effect. Before the drainage
tube was removed, the skull CT was rechecked, and the
hematoma cavity was further reduced. The cranial CT was
reexamined before discharge. Bilateral hematoma dis-
appeared in 114 patients, unilateral hematoma disappeared in
29 patients, with a small amount of compensatory crescent
very low-density shadow subdural effusion in the other side,
and bilateral compensatory crescent very low-density shadow
subdural effusion in 10 patients. There was no space occu-
pying effect and intracranial gas disappeared (Figure 1).
3.3. Comparison of Operation Indexes of Patients.
Compared with the patients in the drilling drainage group,
the operation time was prolonged, the extubation time was
shortened, the amount of postoperative hematoma was
reduced, and the displacement of drainage tube, recurrence
rate, and hematoma clearance rate were improved in the
neuroendoscopy group, but there was no significant dif-
ference in hospital stay and Markwalder score (Table 2).
4. Discussion
CSDH is one of the common disorders in neurosurgery. The
incidence of chronic subdural hematoma is on the rise as the
population ages. CSDH is more common in older men with
a history of mild head trauma, and the source of bleeding
and pathogenesis are not fully understood [13, 14]. The
traditional view is that slight head trauma causes the tear of
bridging vein and a small amount of subdural bleeding. After
bleeding, it is secondary to hyperfibrinolysis and the increase
of local fibrin degradation products, resulting in the con-
tinuous bleeding of new capillaries and the gradual increase
of hematoma [15, 16]. CSDH accounts for about 10% of all
intracranial hematomas, and bilateral CSDH accounts for
about 16%–20% [17–19] of all CSDH.
The recurrence rate of bilateral CSDH is high, and the
clinical manifestations are changeable. Nausea and vomiting
are common, and hemiplegia is rare. It is considered that
bilateral hemorrhage leads to the relative balance of bilateral
cerebral hemisphere compression, and the probability of
midline deviation is small [20, 21]. For bilateral CSDH, some
studies suggest that bilateral simultaneous decompression
should be given as soon as possible, and even cases with only
mild neurological deficit should be actively treated. It is
proposed that MRI examination of T1 low signal and T2
high and low mixed signal indicates that it will deteriorate
3
Drilling drainage (n � 79) t/X2 P
49/30 0.998 0.318
61.27 ± 10.94 0.932 0.353
33 (41.77) 0.448 0.503
23 (29.11) 0.082 0.774
40 (50.63) 0.838 0.360
31 (39.24) 0.276 0.600
143.59 ± 18.07 1.566 0.120
2.39 ± 0.37 0.579 0.563
rapidly and need urgent surgical treatment [22–24]. In terms
of treatment methods, some studies believe that there was no
significant difference in complications and hospital stay
between extended resection of fibrous membrane of he-
matoma after large bone flap craniotomy and local drilling
fibrous membrane resection, but the former can reduce the
recurrence of hematoma [25–27]. Some studies believe that
middle meningeal artery embolization can prevent hema-
toma expansion and recurrence in patients with recurrence
after multiple surgical treatments [28]. At present, bilateral
drilling drainage is recommended for most patients with
bilateral CSDH [29].
Neuroendoscopy can help identify and destroy new
membranes, septa, and solid blood clots and stop bleeding
under direct vision. The endoscopic monitoring system can
guide the operation and avoid blind operation [30, 31].
Endoscopy can not only clearly see the shape, structure,
adhesion, and separation of the capsule but also separate and
open the separation of the organized adhesion in the he-
matoma cavity under direct vision, which greatly improves
the thoroughness of hematoma removal [32–34]. Neuro-
endoscopy can directly stop other obvious small active
bleeding in the cavity with endoscopic bipolar electro-
coagulation, which reduces the incidence of postoperative
rebleeding.
The results of this study showed that in the patients who
received bilateral drilling drainage and neuroendoscopic
assisted drainage, the bilateral hematoma cavities of most
patients were almost closed one day after operation, and a
small number of patients had a small amount of intracranial
gas. There was no death or major complications, which
showed that the effects of bilateral drilling drainage and
neuroendoscopic assisted drainage were good. Compared
with the patients in the drilling drainage group, the oper-
ation time was prolonged, the extubation time was short-
ened, the amount of postoperative hematoma was reduced,
and the displacement of drainage tube, recurrence rate, and
hematoma clearance rate were improved in the neuro-
endoscopy group, but there was no significant difference in
hospital stay and Markwalder score.
The above results show that drilling drainage and
neuroendoscopic assisted drainage have good therapeutic
effects on patients with bilateral CSDH. Neuroendoscopy
has the advantages of extubation time period, low mis-
placement and recurrence rate of drainage tube, low amount
of postoperative hematoma and high clearance rate of he-
matoma. When the surgical conditions are met, the way of
neuroendoscopic assisted drainage may be more conducive
4 Computational Intelligence and Neuroscience

(a) (b) (c) (d)

(e) (f ) (g) (h)

Figure 1: Preoperative and postoperative imaging examination of patients. (a) Preoperative MRI T1 weighted imaging of a patient in
neuroendoscopy group. (b) Preoperative MRI T2 weighted imaging of a patient in neuroendoscopy group. The preoperative MRI results
showed that there were different degrees of hematomas on both sides of the patient’s brain. (c) CT image of a patient in neuroendoscopy
group one day after operation. The hematoma area of the patient decreased significantly. (d) CT images of a patient in neuroendoscopy
group one day before discharge. The bilateral hematoma cavities of the patient were almost closed. (e) T1 weighted MRI of a patient in
drilling drainage group before operation. (f ) Preoperative MRI T2 weighted imaging of a patient in drilling drainage group. Bilateral
subdural hematoma was diagnosed. (g) CT images of one patient in drilling drainage group one day after operation. The patient’s unilateral
hematoma cavity was almost closed. (h) CT image of a patient in drilling drainage group one day before discharge. The patient’s bilateral
hematoma cavity was almost closed.

Table 2: Comparison of surgical indexes between the two groups of patients.

Clinical data Neuroendoscopy (n � 74) Drilling drainage (n � 79) t/X2 P
Operation time (min) 49.76 ± 6.08 34.67 ± 5.23 16.490 0.000
Hospital stay (d) 14.65 ± 1.79 14.16 ± 1.83 1.673 0.097
Extubation time (d) 4.21 ± 0.85 5.76 ± 0.94 10.670 0.000
Misplacement of drainage tube 0 (0.00) 6 (7.59) 5.850 0.016
Recrudescence 1 (1.35) 7 (8.86) 4.348 0.037
Postoperative hematoma volume (mL) 21.64 ± 4.67 45.08 ± 6.72 24.900 0.000
Hematoma clearance rate 89.64 ± 7.18 74.95 ± 8.67 11.370 0.000
Markwalder 0.86 ± 0.09 0.83 ± 0.11 1.839 0.068

to the treatment and prognosis of patients with bilateral Acknowledgments

CSDH. However, due to the small sample size of this study,
some results may be biased. In the later stage, we still need to
collect more samples and relevant clinical indicators for
more detailed research and discussion.
Data Availability
No data were used to support this study.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
This study was supported by the Talent Start-Up Fund of
Affiliated Hospital of Jiangsu University (no. jdfyRC2019009).
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