Abstract

Background: There are many surgical techniques to treat chronic subdural hematomas (CSHs). However, they all have high recurrence rates. Recently, embolization of the middle meningeal artery (MMA) following surgical evacuation of CSH has reduced the recurrence rate. We investigated the feasibility of combining the surgical obliteration of the MMA at the same time as the placement of a burr hole for evacuation of the CSH.

Case Description: We report on nine patients who underwent 11 of these combined procedure by the same surgeon in two hospitals, including clinical data and images during the perioperative and postoperative periods. Cardoso had previously reported details of the surgical technique. Two patients underwent bilateral procedures. Two patients had two burr holes because the hematomas did not extend caudally to the pterion, where the MMA enters the calvarium. Intraoperative fluoroscopy was used to locate the point of entry of the MMA into the calvarium in most cases, except in two instances when navigation was utilized.

Conclusion: This small series of nine cases suggests the feasibility of using this combined procedure as an additional option to the treatment of CSHs, especially where endovascular treatment might not be readily available. Furthermore, it has the potential advantages of safety, efficacy, avoidance of a second endovascular procedure, faster disappearance of the subdural collection, lesser exposure to radiation, and cost containment. Larger prospective controlled series are needed to identify its potential usefulness.

Keywords: Arterial coagulation, Burr hole, Chronic subdural hematoma, Middle meningeal artery, Subdural recurrence

INTRODUCTION

We had previously reported a clinical case to demonstrate the feasibility of a modified surgical technique for drainage of chronic subdural hematomas (CSHs). It involved the strategic placement of a pterional burr hole at the origin of the intracranial portion of the middle meningeal artery (MMA), thus allowing drainage of the hematoma with simultaneous coagulation of the MMA.[ 4 ] We now report on an additional nine cases using this novel procedure. We believe that these additional cases lend credibility to this method of locating the MMA by the combination of surface landmarks and intraoperative fluoroscopy in most cases, as well as providing further initial evidence for its feasibility, reliability, and safety.

CASE DESCRIPTION

This is a retrospective review of 11 procedures performed on nine patients by the same surgeon between January 2019 and December 2022 in two separate hospitals [ Table 1 ]. The surgical technique for simultaneous drainage of the CSH and coagulation of the MMA was performed according to previously reported.[ 4 ] All patients consented to the procedure, including the performance of burr hole(s) and coagulation of the MMA. Whenever patients agreed, the procedure was performed under sedation and local anesthesia of the scalp, with the head resting on a donut-shaped headrest.

Table 1:

Summary of cases.

Description of the surgical procedure

The surgical procedure has been described in detail with the first patient reported in the literature.[ 4 ]. The procedure is ideally performed under local sedation unless there are individual preferences or medical reasons against that. The patient is placed in the supine position with the ipsilateral shoulder raised over a foam roll. The head rests on a horseshoe headrest or is secured by means of 3-pin skeletal fixation if preferred by the surgeon. The pterional burr hole is at the middle meningeal calvarial entry point, corresponding to the tip of the greater sphenoid wing. This location is identified by:

External surface landmark measurements: The point where a 3.5-cm line from the posterior edge of the superior portion of the zygomatic process of the frontal bone intersects with a 5.5-cm line drawn from the external acoustic meatus (here referred to as the zygomatic-meatal angle) as previously described.[ 4 ]

After preparation of the surgical field, the scalp and temporalis muscle are infiltrated with local anesthesia, and a 3.5-cm coronal incision is centered at the middle meningeal calvarial entry point. The temporalis muscle fascicles are bluntly retracted sideways along its fibers, then held by a 2-prong Weitlaner 4” self-retaining retractor. A small burr hole is then fashioned using a match-stick drill bit, which allows the visualization and bipolar coagulation of the branches of the MMA at its bifurcation before opening the dura mater [ Figure 1 ].

Figure 1:

Surgical exposure demonstrating the size of the incision and the middle meningeal bifurcation at the tip of a 12-gauge suction tip.

The evacuation of the hematoma is then carried out in standard fashion. The operating table can be tilted, if needed, to drain distal portions of the hematoma by the use of gravity gradients. If desired, washing off residual blood by means of a red rubber catheter can also be done. The small surgical wound is then closed in layers.

On only two occasions, navigation was used to locate the MMA, details of which are provided below (cases 2 and 3).

Case 1

This was an 80-year-old right-handed male who presented with mental confusion and imbalance following a fall with a head strike. Four weeks previously, the patient had undergone a left frontal burr hole and right craniotomy simultaneously for evacuation of bilateral subdural hematomas elsewhere, with satisfactory clinical response and postoperative images.

On neurological examination, the patient was alert and confused, only orientated to name and with mild right hemiparesis. The computed tomography (CT) scan of the head showed recollections of bilateral subdural hematomas, much larger on the left, producing a mass effect and left-to-right midline shift [ Figure 2a ].

Figure 2:

(a) Preoperative and (b) postoperative images showing progressive disappearance of the subdural collection at one day, (c) eight days and (d) 9 weeks following the left pterional burr.

Evacuation of the recurrent left subdural hematoma was accomplished by performing a left pterional burr hole with coagulation of the MMA, according to the technique described above. Due to a lack of cooperation, the procedure was performed under general anesthesia with the head in skeletal fixation.

Postoperatively, the patient improved quickly. On the 1^st postoperative day, his speech became increasingly coherent and the right hemiparesis resolved. The patient was fully alert and oriented by postoperative day 2. At 1 month follow-up, the patient continued to show improvements of balance and only occasional mild episodes of confusion. Sequential postoperative CT scans performed on days 1, 8, and 9 weeks after surgery demonstrated progressive resolution of the subdural collections [ Figure 2b - d ].

Case 2

This was a 63-year-old female admitted after a suicidal attempt by ingestion of 14 tablets of Ambien. She reported a fall downstairs 5 weeks previously when she hit her head against the heater, sustaining two scalp lacerations. She then developed increasing headaches, dizziness, and depression. The neurological examination was normal, except for slight weakness of bilateral intrinsic hand muscles and mild weakness of the right knee extension, with bilateral patellar hyperreflexia. At 5 weeks post-injury, the patient continued to complain of headaches, photophobia, and dizziness and was started on a trial of oral steroids, with no improvement of symptoms and findings on examination. The patient demanded general anesthesia. The procedure was carried out according to the previous description, except for the use of frameless stereotaxy navigation for the location of the point of entry of the MMA to the calvarium, as the placement of the burr hole at the calvarial entry of the MMA can also be identified by frameless navigation if desired [ Figure 3 ]. A well-formed subdural outer membrane was encountered.

Figure 3:

(a) Navigation landmarks to locate the burr hole placement: coronal and (b) axial bone density CT slices showing the “open” groove (solid arrows), where the MMA leaves its intraosseous portion (hollow arrow on the contralateral side) to enter the calvarium.

The symptoms disappeared immediately after the procedure, and the patient returned to normal activities within 2 weeks. Sequential CT scans showed the disappearance of the subdural collection by 4 weeks [ Figure 4 ].

Figure 4:

Sequential head CT scans: (a) Five weeks after the injury, when steroid therapy was attempted. (b) Four weeks later, when the symptoms remained unchanged. (c) Postoperative images one week after surgery and (d) four weeks after surgery.

Case 3

This was a 77-year-old right-handed man who presented with headaches and dizziness following a fall backwards down one flight of stairs, with a head strike and without loss of consciousness.

On examination, the patient was awake and oriented times 3, with a left occipital scalp contusion and hematoma. Cranial nerves were intact, and there were no motor or sensory abnormalities.

The head CT scan showed bifrontal lobe contusions, pneumocephalus, left medial maxillary wall fracture, a linear fracture of the left occipital bone, and chronic bilateral subdural collections. The latter had increased in size when compared to magnetic resonance imaging 9 months previously. Repeat imaging revealed an increase in the size of the subdural collections, especially on the right, accompanied by increasing headaches [ Figure 5a ].

Figure 5:

(a) CT prior to surgery. (b) Three weeks after right burr hole evacuation and MMA coagulation and (c) three months after the same procedure on the left side.

The patient was placed under general anesthesia and had head pin fixation. The localization for the right burr hole at the pterional region was made by means of Stryker navigation, similar to the description for Case 2, as shown in Figure 3 . The procedure was carried out as previously described, and coagulation of the MMA and evacuation of the subdural collection were uneventful.

By the 1^st postoperative day, the patient was free of headaches and dizziness. The patient then refused placement in an intermediate care facility. Once home, he experienced several falls, striking his head on the last one. He reported no loss of consciousness during any of the falls.

On examination for the second admission, the patient was awake and oriented times 3. There was a new laceration over the left frontal region, overlying a scalp hematoma. The contra-lateral burr hole incision was healing well.

The head CT scan showed resolution of the right-sided subdural collection but enlarging subacute left subdural hematoma, with evidence of recent rebleeding and increase in the left-to-right midline shift [ Figure 5b ].

The patient underwent a contralateral evacuation of the subdural hematoma by means of a pterional burr hole and coagulation of the left MMA, according to the technique described above.

The postoperative course had no adverse neurological events. Head CT scans on postoperative day 5 showed complete resolution of both subdural collections. On an outpatient follow-up 3 months later, the patient remained asymptomatic, neurologically normal, and caring for himself at home [ Figure 5c ].

Case 4

This was a 67-year-old right-handed woman who presented with increasing headaches after falling down three steps at home earlier that day, with a witnessed head strike. On examination, there was a left scalp laceration; the patient was alert and oriented times 3 and had a non-focal neurological examination. The head CT showed a small left frontal hygroma [ Figure 6a ]. Aspirin was discontinued.

Figure 6:

(a) Sequential CT images at the time of injury and (b) two months later. (c) CT scout image of both burr holes: the pterional one (black arrow) over the groove of the MMA. (d) CT at four weeks postoperative.

On follow-up 2 months later, the patient continued to have headaches and dizziness, especially on getting up from the lying position. The neurological examination continued to be normal. A follow-up head CT scan demonstrates the conversion of the left-sided hygroma into a CSH, with an increase in volume and signal intensity [ Figure 6b ].

The patient opted for general anesthesia. A left pterional burr hole was placed according to the previously described technique, with the assistance of intraoperative fluoroscopy.[ 4 ] The MMA was coagulated, and a small amount of subdural fluid was drained. This prompted the placement of a second parietal burr hole over the thickest portion of the subdural hematoma, resulting in satisfactory drainage of subdural fluid [ Figure 6c ]. There were no surgical complications.

Headaches and dizziness resolved within the next few days. On 4 4-week postoperative follow-up, the patient had no complaints. CT scan of the head demonstrated complete resolution of the previously existent subdural hematoma [ Figure 6d ].

Case 5

This was a 50-year-old male with multiple previous visits to the emergency room who complained of mild aching headaches following a fall with a head strike the same day while intoxicated. There was no loss of consciousness. The patient had suffered another head injury earlier that week: a hammer blow to the right forehead, again with no impairment of consciousness, but followed by vomiting. The only comorbidity was chronic alcoholism.

On physical examination, there were abrasions to the right forehead and right lateral temporal area. The patient was awake, alert, orientated, and following commands but mildly agitated, with a Glasgow coma scale score of 15. The neurological examination and vital signs were normal.

The CT scan of the head demonstrated an acute on chronic left temporal subdural hematoma, with a midline shift of 4.4 mm, which extended to the tentorium. The subdural hematoma was evacuated by means of a left pterional burr hole and coagulation of the MMA, as described above.

Postoperatively, the patient’s headaches improved, and he remained neurologically stable. Follow-up head CT scan at 3 months demonstrated complete resolution of the subdural collection.

Case 6

This was an 86-year-old woman who presented with altered mental status after being found lying in the bathroom for several hours. On examination, the patient looked generally well and was confused but cooperative. The neurological examination was non-focal.

Comorbidities included hypertension, diabetes mellitus, dementia, and seizures. Her medication included amlodipine, aspirin, atorvastatin, escitalopram oxalate, hydrochlorothiazide, insulin, levetiracetam, losartan, metformin, and Vitamin A. On the day of admission, she experienced a generalized tonic-clonic seizure requiring intubation.

Head CT scans, before and after the seizure, showed a right CSH with layering of signal intensity indicating rebleeding. It also showed effacement of ipsilateral sulci and midline shift.

Due to the wider distribution of the subdural collection over the right hemisphere, as well as the presence of recent bleeding in the posterior parietal portion of the subdural collection, two burr holes were placed. The left pterional burr hole was performed according to the technique described above. The MMA was coagulated, and clear xanthochromic fluid was drained. The other ipsilateral burr hole was placed over the right parietal region, similar to the one described in Case 4. The parietal opening led to a well-formed outer subdural membrane and liquefied xanthochromic subdural fluid followed by dark, fresh blood. The patient was extubated at the completion of the procedure. An early CT scan showed a satisfactory appearance.

The symptoms disappeared after the procedure; the patient was discharged with home care and disappeared to follow-up. She returned a year later with a contralateral stroke. The subdural collection had completely disappeared.

Case 7

This was a 68-year-old male who presented to the emergency department with cognitive impairment, lethargy, and urinary incontinence after sustaining a fall from standing in a parking lot while intoxicated on the same day of admission. Medical history revealed alcoholism, active smoking, imbalance, use of a cane, and urinary incontinence.

On examination, the patient was disoriented to time and place. There was spasticity of all four limbs, pain on mobilization of the left shoulder, and diffuse atrophy of intrinsic muscles of both hands. Motor power was symmetrical in all limbs. There was a left periorbital hematoma with abrasions to the left forehead, bilateral abrasions on both hands and bilateral pitting edema.

The head CT scan showed bilateral chronic subdural collections, much larger on the left and with evidence of recent rebleeding. Imaging also showed spondylotic cervical cord compression, which explained the bilateral spasticity.

The patient first underwent placement of a left pterional burr hole and coagulation of the MMA under local anesthesia, according to the technique described above. Intubation was avoided due to the coexistent compressive cervical myelopathy. A well-formed outer membrane was found, leading to old blood initially followed by fresher fluid bleeding. There was an improvement in the patient’s condition after surgery. However, he continued to be weaker and spastic on the left side, and there was an increase in the size of the contralateral right subdural collection. Therefore, 5 days later, the patient underwent another uneventful pterional burr hole and coagulation of the MMA on the contralateral right side, again under local anesthesia. He recovered well after both procedures. Later on, during this admission, the patient underwent decompressive surgery to the cervical spinal cord.

On 4 week follow-up, there were no longer any neurological deficits. Cognition had improved, but the patient continued to be intermittently disoriented. Sequential head CT scans demonstrated ongoing bilateral improvement with a decrease in the size of both subdural collections. At 7 weeks postoperatively, the patient’s neurological status and cognition were back to normal. The patient was transferred from rehab to home. The CT scan of the head showed minimal residual collections on both sides.

Case 8

This was a 62-year-old man, an active soccer player, who had undergone a previous left mini-craniotomy for evacuation of an acute subdural hematoma 10 weeks previously. At that time, he was hit on the head with a ball while playing soccer. On follow-up, he complained of lethargy and lack of drive. He had been placed on dexamethasone elsewhere. He had quit playing soccer since the initial surgery. There were no comorbidities.

On examination, the patient’s cognition was intact, and the neurological examination was normal. The head CT scan showed findings consistent with residual/recurrent subacute left subdural hematoma.

Under general anesthesia, the patient underwent a left burr-hole placement with coagulation of the MMA, according to the technique described above. The postoperative course was uneventful; the patient was asymptomatic and continued to have a normal neurological examination at 1 week and 4 months, with progressive disappearance of the subdural collection during this time interval.

Case 9

This was a 42-year-old right-handed man with multiple visits to the emergency room for injuries related to alcohol abuse. On this visit, the patient was intoxicated, complaining of pains involving the entire left side of the body following a fall 3 days previously. Medical history included a chronic right subdural hematoma treated conservatively for the past month, a remote left hemiparesis from a right cerebral stroke treated elsewhere, and a substance abuse disorder.

On preoperative examination, the patient was alert and cooperative, with normal cranial nerves and spastic left hemiparesis attributed to the old stroke.

Sequential head CT scans revealed a preexistent (3 weeks earlier) right CSH on the same side as an atrophic brain from a previous large middle cerebral artery infarct [ Figure 7a ]. Immediately after the injury, this increased into a larger subdural collection of mixed signal intensity, indicative of acute rebleeding into an older chronic subdural collection and consistent with the history of repeated falls [ Figure 7b ]. There is further rebleeding 3 days later, which caused effacement of the right cerebral sulci over the convexity despite a large area of ipsilateral encephalomalacia [ Figure 7c ].

Figure 7:

(a) Sequential CT showing a preexistent right chronic subdural hematoma. (b and c) Following repeated falls, there was continued increase in the subdural collection of higher signal intensity, indicative of rebleeds. (d) Postoperative image ten weeks after surgery.

A right burr hole and MMA coagulation were performed under general anesthesia, according to the above-described technique.

The procedure was well tolerated, and the patient returned home at baseline neurological status. Postoperative imaging at 10 weeks was very satisfactory because, despite ipsilateral cerebral atrophy, there was complete resolution of the subdural collection [ Figure 7d ].

DISCUSSION

The first successful surgical evacuation of CSHs is attributed to Hulke in 1883.[ 9 , 24 , 25 ] Since then, surgeons have devised different options for the surgical evacuation of symptomatic CSHs. At present, there is no unanimous agreement as to the best surgical method of treatment.[ 7 , 10 , 12 , 14 , 17 , 21 , 24 , 25 ] While these procedures are effective and carry low complication rates, they are accompanied by a high risk of recurrences.[ 1 , 7 , 11 , 14 , 17 , 20 , 21 ] At the beginning of this century, Japanese investigators devised the successful use of postoperative embolization of the MMA to deal with such recurrences.[ 15 , 22 , 23 ] We then demonstrated the feasibility of combining the ligation of the MMA with the burr-hole drainage of the subdural collection in one single procedure.[ 4 ] This combination was also theoretically considered by other investigators.[ 8 ] They reported on landmarks and anatomical considerations related to the idea of combining the occlusion of the MMA with the surgical evacuation of CSHs into a single procedure.[ 8 ] While reviewing 1454 CT scans of patients harboring a CSH, Haldrup et al. found that most of the subdural collections were anteriorly located and, therefore, within the blood supply territory of what they called the “anterior branch” of the MMA.[ 8 ] The nomenclature of the branches of the MMA varies among different authors.[ 3 , 16 , 18 ] We opted to call the branch of the MMA, which enters the calvarium at the pterion, the main branch of the MMA. Its location is very predictable. Using the simple method described by Cardoso previously, we were able to locate the MMA in the pterion in all cases described here without the need to extend the burr hole. Imaging confirmation of the location for placement of the pterional burr hole can either be achieved by means of intraoperative fluoroscopy or preoperative navigation of computerized tomographic images. Navigation was only used in two of our cases. For simplicity of use, as well as cost containment, we used fluoroscopy in most of our cases, as described by Cardoso in the original description of the procedure.[ 4 ] If CT navigation is used, the target is chosen by the location where the intraosseous canal of the MMA first becomes a groove of the inner table of the skull at the pterion, as shown in Figure 3 . In two patients, two burr holes were used, either because the hematoma did not extend downward as far as the pterion or because there was evidence of fresh rebleeding far away from the site of the pterional burr hole. There was no recurrence of subdural hematomas in any of the nine cases. Recurrence was defined as (a) increased subdural collection on serial images, as compared to the first postoperative image, and/or (b) re-appearance of symptoms after initial clinical improvement.

More recently, large clinical series have shown that embolization of the MMA following surgical evacuation of CSHs reduces subdural re-accumulation.[ 5 , 6 , 10 , 13 , 19 ] Our results suggest the possibility of an alternative approach to decrease the recurrence rate of the subdural collection, namely, the combination of drainage of the subdural collection coupled with coagulation of the ipsilateral MMA in the same procedure. If proven effective in prospective controlled clinical series, the procedure has the potential to be more useful in locations where endovascular technology might not be easily available. Furthermore, if, in the future, one wishes to take this approach a step further, it could be combined with the intraoperative injection of an embolizing agent directly into the MMA. In our preliminary and small series, there were no procedure-related complications and no need for reoperations. There was an immediate decrease in size and faster disappearance of the subdural collection as compared with the reported series using MMA embolization.[ 2 ]

The combination of two interventions, namely, burr-hole drainage of the subdural hematoma plus coagulation of the MMA, into a single minimally invasive procedure appears to be feasible and associated with minimal invasiveness (local or general anesthesia), cheaper price, immediate clinical response, and decreased exposure to radiation. In patients where the subdural collection does not extend to the middle meningeal calvarial entry point, there is the option of the placement of a secondary burr hole.

CONCLUSION

The results of this short series suggest that this combined procedure could safely be considered a choice among the multiple surgical options for drainage of CSHs. The combination of drainage of the subdural collection and simultaneous coagulation of the MMA offers the potential advantages of (a) cost saving by avoiding a second open surgical or endovascular procedure, (b) faster reabsorption of the subdural collection and reversal of symptoms, (c) lesser exposure to radiation, (d) shorter follow-ups, and (e) need for less postoperative imagining. Obviously, larger prospective clinical studies will be needed to ascertain the safety, efficacy, and indications of this procedure as part of the armamentarium for the management of CSHs. Pending the confirmation of its efficacy by larger prospective trials, this procedure might be particularly relevant in developing countries, where the option of endovascular embolization of MMA may not be so readily available and cost containment a more relevant consideration.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

Acknowledgement

We are indebted to Mr. Christopher Boyd for his contributions to the illustrations.

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