Single Burr Hole Research Articles

Surgical Outcome of Brain Abscess after Single Burrhole Aspiration Technique in Terms of Glasgow Outcome Scale

Objectives: This case-series was aimed to determine the surgical outcome of brain abscess after a single burr hole aspiration technique in terms of the Glasgow outcome scale (GOS).
 Material & Methods: 100 cases were taken in the study with brain abscess. The favourable outcome included those patients with postoperative GOS of 4 or 5, at discharge and one month postoperatively whereas unfavourable outcome included patients with postoperative GOS of less than 4, at discharge and one month postoperatively.
 Results: Of the 100 patients included, there were 72 (72%) males and 28 (28%) females. The overall mean diameter of the abscess was 6.01 cm ± 1.90. Mean GOS was 2.95 ± 0.86 while mean GOS 3.79 ± 1.18. In this study 75% (n=75) patients presented with a GCS of 12 or less. Among these patients, 2 patients presented with a GCS of 5, 6 patients with a GCS of 7, 9 with GCS 8, 11 with GCS 9, 18 with GCS 10, 15 with GCS 11 and 14 patients presented with a GCS of 12. A favourable outcome was observed in 73 (73%) patients (GOS = 4 and 5), while 27 (27%) were in the unfavourable outcome group.
 Conclusion: Although most of the patients present with a good neurological state, those who present with lower GCS are particularly prone to the poor postoperative outcome and higher mortality. The size of the brain abscess is also an important predictor of the postoperative outcome. The overall outcome for brain abscess aspiration was good.

Neuroendoscopic followed by microsurgical approach for the treatment of pilocytic astrocytoma of the pineal region

Pilocytic astrocytoma is a low-grade tumor that can affect the pineal region and has a potential life-threatening presentation with obstructive hydrocephalus. This video presents the case of a child who underwent an endoscopic third ventriculostomy with tumor biopsy and for whom a supracerebellar infratentorial approach was chosen after confirmation of the diagnosis of a pilocytic astrocytoma. Herein, we discuss the technical details of both procedures, such as the single burr hole in the neuroendoscopic approach, the ventricular landmarks and identification of the venous sinus through neuronavigation, the anatomical landmarks during the supracerebellar infratentorial approach, and the use of ultrasonographic aspiration.

Improvement of Headache in Patients after Occipital Extradural Hematoma (EDH) with Less Than 15 ml of Volume after Single Burr Hole Evacuation and Placement of Drain

Objective: We hypothesized that if we operate occipital extradural hematoma (EDH) having a volume less than 15 ml by single burr hole evacuation of extradural hematoma (EDH) and placement of drain without doing craniotomy then clinical status of the patients particularly headache improves.
 Method: An observational study of 15 patients (with presenting GCS: 8–13) was conducted on patients who were operated in Punjab Institute of Neurosciences (PINS). All patients had acute extradural hematoma less than 15 ml after a road traffic accident (RTA). The age range was 22 – 45 years. All patients were operated on within 12 hours of road traffic accident. The timing of surgery was in the range of 1-2 hours.
 Results: In all patients, surgery was performed by a single burr hole at the occipital region at the site of occipital EDH and the drain was placed in an extradural position. Co-morbidities in our patients were DM, polytrauma. Receiving GCS was 9 in 2 (13.33%) patients, was 13 in 10 (66.67%), was 8 in 1 (6.66%) patient and receiving GCS was 15 in 2 (13.33%) patients. All patients were assessed clinically on 5th post-operative day. It was seen headache was relieved on 5th post-operative day in all patients except 1 (6.66%) patient. Our 1 (6.66%) patients came for follow-up with the complaint of headache and vomiting which was managed conservatively.
 Conclusion: Surgery by single burr hole evacuation and placement of drain is a safe method if occipital EDH is less than 15 ml in volume

Single Burrhole Craniostomy with Subdural Placement of Foley Catheter for Drainage of Chronic Subdural Hematoma

Objective: Chronic subdural hematoma (CSDH) is a common neurosurgical condition of the elderly. The lack of consensus over a single standard surgical procedure for the management of CSDH urges neurosurgeons to evaluate different techniques in terms of a better outcome.
 Material & Methods: In this prospective study forty cases of CSDH who had undergone single burr-hole craniostomy and subdural placement of Foley catheter were analyzed. The observations were made concerning clinical, radiological findings, postoperative complications, and mortality rate.
 Results: The study included 26 males and 14 females with a mean age of 67 years. The most common presenting symptom was hemiparesis (n=18, 45%). Recurrent hematoma and recurrent evacuation rate was 10%. There was no case of newly developed postoperative seizures, pneumocephalus, intracranial hemorrhage, and wound infection. The mortality rate during the study was 0.0%. The mean Glasgow outcome score (GOS) at the time of discharge was 4.8.
 Conclusion: We concluded that single burr-hole evacuation of CSDH with Foley catheter placement appears to be an effective procedure with a significant reduction in postoperative pneumocephalus. Factors such as sudden decompression of hematoma, the air in the subdural cavity, misplacement of drainage tubes, and damage to blood vessels during surgery can be reduced with this technique.

Occipital interhemispheric transtentorial approach to a pineoblastoma in a 4-year-old child.

The authors present a pediatric case of a pineoblastoma treated with gross-total removal through an occipital interhemispheric transtentorial approach (OITA). The child presented with acute hydrocephalus that was treated by endoscopic third ventriculostomy (ETV) and tumor biopsy through a single burr hole. Histology revealed a pineoblastoma. Microsurgical total removal was performed 3 months after neoadjuvant chemotherapy. OITA was chosen on the basis of the tumor’s location below the Herophilus-Galen line of sight. In this video, the authors show the positioning, the operating devices, the approach, and the microsurgical dissection, indicating all the neurovascular structures encountered.The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2122.

Single versus double burr holes evacuation in the treatment of chronic subdural hematoma

Background: Chronic subdural hematoma (CSDH) is a well-known entity and common surgical disorder managed by the neurosurgeon and, if not recognized and treated timely, may prove fatal. It can be non-traumatic or post-traumatic and all of them need urgent attention irrespective of aetiology. It manifests with a progressive neurologic deficit that occurs >3 weeks following head injury. The principal techniques used in the treatment of CSDHs presently are burr hole, twist drill craniostomy, craniectomy and craniotomy. Objective: The aim of this study was to assess clinical outcome in unilateral chronic subdural hematoma patients treated by single or double burr-hole drainage. This prospective study was carried out at the Department of Neurosurgery, IMS, BHU, Varanasi from September 2016 to August 2018. A total of 60 patients with their age ranged from 22to 88 years with GCS 6 to 15 & hematoma thickness 10mmc were included in this study and randomly divided into two groups using random allocation software. In group A, patients with chronic subdural hematoma (CSDH) were managed with single burr-hole drainage. In group B, patients were managed with double burr-hole drainage. Clinical outcome was measured on the1st postoperative day, 3rd postoperative day and 7th postoperative day by GCS and at 1month follow-up by measuring the Glasgow outcome scale (GOS). Result: In this study double burr-hole drainage and single burr-hole drainage surgery shows equal success in the management of CSDHs with single burr hole taking less operative time.

Post-Operative Complications of Surgery for Chronic Subdural Hematoma (SDH) and Prevention

Objective: The study aimed to determine the rate and type of complications during surgery for treatment of chronic subdural hematoma and assess ways for their prevention.
 Material and Methods: A total of 50 patients of chronic SDH were selected from the Neurosurgery Department of Bahawal Victoria Hospital. Patients were treated surgically with a single burr hole evacuation under local anesthesia, introduced a subdural drain, nursed in a head-down position for 24 hours, and given plenty of fluids orally and intravenous route. The surgical technique involved a formation of a single burr hole at the point of maximum density.
 Results: Out of 50, 43 patients recovered smoothly postoperatively and discharged on the 7th postoperative day. Two patients were re-operated due to inadequate evacuation or reaccumulation. One patient developed subdural empyema post-operatively and expired in spite of good antibiotic cover. In one patient subdural drain penetrated the brain parenchyma resulting in dysphasia. Another patient formed an intracerebral hematoma due to irrigation of the cavity with pressure. One patient with GCS 4/15 developed seizures postoperatively and expired after one hour. One patient developed gross subdural tension pneumocephalus after removing the subdural drain was re-operated and recovered.
 Conclusion: Single burr hole evacuation of chronic SDH under local anesthesia is the most accepted surgical treatment. Using proper aseptic surgical techniques, the introduction of the minimum necessary length of the subdural catheter to avoid penetration into the brain parenchyma, followed by careful irrigation of the subdural cavity can help prevent complications.

Intraoperative hematoma volume can predict chronic subdural hematoma recurrence.

Background: We routinely measured the exact chronic subdural hematoma (CSDH) volume during single burr hole surgery. To date, several risk factors have been reported for CSDH recurrence, including sex, hematoma volume and degree of midline shift calculated from computed tomography, use of anticoagulants or antiplatelet medications, and alcohol consumption habits. The aim of this study was to clarify whether hematoma volume, in conjunction with other factors, can predict recurrence.Methods: We retrospectively reviewed the clinical data of 194 consecutive patients with CSDH who underwent single burr hole surgery. The risk factors for recurrence were analyzed based on patients’ sex, age, bilaterality, existence of apparent trauma history, exact intraoperative hematoma volume, and various clinical factors, including preoperative anticoagulant/antiplatelet intake.Results: Recurrence occurred in 22 patients (11.3%). Multivariate logistic regression analysis revealed that intraoperative hematoma volume was an independent risk factor for CSDH recurrence (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01–1.02, P < 0.001), in addition to sex (male) (OR 9.25; 95% CI, 1.00–84.8; P = 0.049) and diabetes mellitus (DM) (OR: 3.97, 95% CI, 1.34–11.7, P = 0.013). Based on receiver operating characteristics analysis, the cutoff value of the hematoma volume predicting CSDH recurrence was 150 ml (sensitivity and specificity of 72.7% and 72.1%, respectively; area under the curve: 0.7664, 95% CI: 0.654–0.879, P < 0.001). Of these, a hematoma volume ≥150 mL was the strongest independent risk factor for recurrence according to multiple regression (OR: 8.98, 95% CI: 2.73–29.6, P < 0.001) and Cox regression analysis (hazard ratio: 3.05, 95% CI: 1.18–7.87, log-rank P = 0.0046, P = 0.021). Follow-up periods after surgery were significantly longer for cases with recurrence than for non-recurrence cases (24.8 ± 11.5 vs. 15.9 ± 9.7 days), and the recurrence prediction cutoff value was 17 days, with a sensitivity and specificity of 83.1% and 68.2%, respectively (AUC: 0.7707, 95% CI: 0.6695–0.8720, P < 0.001).Conclusion: Intraoperative hematoma volume could be a predictive value for CSDH recurrence.

Electrocorticography During Deep Brain Stimulation Surgery: Safety Experience From 4 Centers Within the National Institute of Neurological Disorders and Stroke Research Opportunities in Human Consortium.

Intraoperative research during deep brain stimulation (DBS) surgery has enabled major advances in understanding movement disorders pathophysiology and potential mechanisms for therapeutic benefit. In particular, over the last decade, recording electrocorticography (ECoG) from the cortical surface, simultaneously with subcortical recordings, has become an important research tool for assessing basal ganglia-thalamocortical circuit physiology. To provide confirmation of the safety of performing ECoG during DBS surgery, using data from centers involved in 2 BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative-funded basic human neuroscience projects. Data were collected separately at 4 centers. The primary endpoint was complication rate, defined as any intraoperative event, infection, or postoperative magnetic resonance imaging abnormality requiring clinical follow-up. Complication rates for explanatory variables were compared using point biserial correlations and Fisher exact tests. A total of 367 DBS surgeries involving ECoG were reviewed. No cortical hemorrhages were observed. Seven complications occurred: 4 intraparenchymal hemorrhages and 3 infections (complication rate of 1.91%; CI=0.77%-3.89%). The placement of 2 separate ECoG research electrodes through a single burr hole (84 cases) did not result in a significantly different rate of complications, compared to placement of a single electrode (3.6%vs 1.5%; P=.4). Research data were obtained successfully in 350 surgeries (95.4%). Combined with the single report previously available, which described no ECoG-related complications in a single-center cohort of 200 cases, these findings suggest that research ECOG during DBS surgery did not significantly alter complication rates.

Analysis of risk factors for prolong hospitalization in chronic subdural hematoma undergoing single burr hole and drainage

Introduction&#x0D; Single burr hole surgery for Chronic subdural hematoma (CSDH) is commonly performed neurosurgical procedure with &gt;90% favorable outcome and less hospital stay. However, sometimes hospital stay may be prolonged due to associated prognostic factors, even in patients with favorable outcome. This study aims to analyze the early outcome of single burr hole and drainage surgery and factors that may be associated with prolong hospitalization.&#x0D; Materials and method&#x0D; A retrospective analysis of the patients who underwent single burr hole and drainage for CSDH from sept 2017 to may 2020 in Nepal Mediciti hospital. The patients with B/L CSDH, who underwent double burr hole and drainage or craniotomy evacuation or conservatively managed patients were excluded from the study. Early outcome was assessed using Glasgow outcome score at 7 days. Effect of use of antiplatelet/ anticoagulant drugs, age, comorbidity, preoperative Glasgow coma score on number of hospital stay was analyzed. Chi-square test was used for statistical analysis in SPSS version 25.&#x0D; Results&#x0D; Out of 85 patients, 73 were male. Mean age was 63.8 years. Early outcome in 7 days was favorable with GOS (4-5) in 90.6%. The use of antiplatelet or anticoagulant drugs was more common amongst patients with age &gt; 70 years (p=0.01). The number of hospital stay was associated with age (p=0.00), antiplatelet or anticoagulant drugs (p=0.00), comorbidities (p=0.001), preoperative GCS(P=0.001) and GOS at 7 days (p=0.001).&#x0D; Conclusion&#x0D; Single burr hole and drainage surgery for CSDH mostly produce favorable outcome. The use of antiplatelet or anticoagulant drugs is more common in patients above 70 years. Age, antiplatelet or anticoagulant drugs, comorbidities, preoperative GCS, GOS at 7 days are related with longer hospital stay.

Single Burr-Hole Extended Transforaminal Approach for Concurrent Endoscopic Surgery in the Third Ventricle Posterior to the Foramen of Monro and Ventriculostomy: Clinical Series and Planning Steps

For endoscopic surgery of third ventricular lesions posterior to the foramen of Monro that frequently require a third ventriculostomy during the same procedure, the extended transforaminal approach (ETFA) through the choroid fissure has been proposed. This study reports clinical results and provides anatomic background and guidelines for individual planning of a single burr-hole approach and a safe transchoroid entry zone. A retrospective review was undertaken of 25 cases of concurrent third ventricle surgery and third ventriculostomy via ETFA. Assessment was made of a safe transchoroidal entry zone on cadavers (6 hemispheres) and of planning guidelines on magnetic resonance imaging showing occlusive hydrocephalus (30 sides). ETFA was feasible in all 25 cases. The safe transchoroid entry zone was sufficient in 16 cases; in 9 cases, additional transchoroid opening with transection of the anterior septal vein was required without clinical consequences. The anatomic study showed a safe transchoroid entry zone of 5 mm (3-6 mm) for posterior enlargement of the foramen of Monro. Individual planning on magnetic resonance imaging of patients with enlarged third ventricles showed an optimal burr-hole position 22 mm (10-30 mm) lateral to the midline and 8 mm (27 to -23 mm) precoronal; a foramen of Monro diameter of 7 mm (3-11 mm) and a safe transchoroid entry zone of 6 mm (3-12 mm). According to our data, concurrent endoscopic surgery of third ventricular lesions posterior to the foramen of Monro and ventriculostomy are feasible through a single burr hole and a transchoroid extension of the transforaminal approach. Precise preoperative planning is recommended for anticipating the individual anatomic nuances.

Surgical occlusion of middle meningeal artery in treatment of chronic subdural haematoma: anatomical and technical considerations.

The primary aim of chronic subdural haematoma (CSDH) treatment is to relieve pressure to improve neurological symptoms. The secondary aim is to avoid recurrence. The blood supply from the middle meningeal artery (MMA) to the haematoma membranes has recently become a research target, to enhance our understanding of the processes leading to growth and re-growth of a CSDH. Several studies indicate that endovascular embolization of the MMA (eMMA) reduces recurrence rates, but this effect must be confirmed in a randomized controlled setting. Endovascular embolization is an advanced and costly procedure carrying a significant risk of embolism in the elderly. The aim of this study was to assess anatomical and technical aspects of surgical occlusion of the MMA (soMMA) via a single same-procedure burr hole, as an alternative to eMMA. Technical aspects of soMMA were assessed using cadaver head dissection. MMA anatomy was examined by mapping the branching pattern and distribution of MMA in dry skulls, and CSDH position was investigated by analysis of computed tomography (CT) of CSDHs. Finally, we evaluated the possibility of CT-guided navigation to mark the branching point of the anterior MMA division on the skin. We established anatomical landmarks to locate the MMA and found that particularly the anterior MMA branch can be occluded through a single burr hole at the pterion during the same procedure as haematoma decompression. CT of 1454 CSDHs in 1162 patients showed that the CSDH was anteriorly located in 57.5% compared with posteriorly in only 3%. This correlated with the anterior branch of the MMA being dominant in 58% of dry skull samples examined. We further confirmed that the MMA can be localized by neuronavigation as an alternative to using anatomical landmarks and average measurements. A CSDH is mainly anteriorly located and supposedly primarily supplied by the anterior MMA branch. In a simulated setting, soMMA can be performed during the same procedure as haematoma decompression. A few reservations notwithstanding, we find that soMMA may be a viable alternative to eMMA in most CSDH cases and that soMMA should be further evaluated in a clinical setting.

Clinical Presentation and Surgical Outcomes of Chronic Subdural Hematoma

Objective: The aim of this study was to access clinical presentation of chronic subdural hematoma and to evaluate the surgical outcome of evacuation of chronic subdural hematoma after single burrhole craniotomy with a close drainage system under local anesthesia.&#x0D; Material &amp; Methods: A descriptive study conducted in the Neurosurgery Department of Khairpur Medical College Sindh. 30 patients of chronic subdural hematoma were included. Patients prepared for evacuation of chronic subdural hematoma through single burr hole followed by closed drainage system for two days.&#x0D; Results: The most common feature was gait disturbance followed by Hemiparesis and headache. Coexisting diseases were hypertension, Diabetes mellitus and Chronic Liver Disease, etc. and causes of CSDH were head injury (trivial trauma) and anticoagulant. Surgical decisions were taken on the bases of clinical presentation and radiological findings of patients. Surgical procedure single burrhole craniotomy followed by irrigation with normal saline and close drainage system for two days. On post-operative follow-up, a recurrence of CSDH occurred in two patients.&#x0D; Conclusion: Single burrhole craniotomy with close drainage system is a simple and safe procedure under local anesthesia for treatment of chronic subdural hematoma.&#x0D; Keywords: CSDH (chronic subdural hematoma), GCS (Glasgow coma score), Burrhole craniotomy, Neurosurgery &amp; Subdural drain.

Chronic subdural hematoma following ventriculoperitoneal shunt: A case report

Chronic Subdural Hematoma (CSDH) is rare complication following ventriculoperitoneal (VP) shunt for hydrocephalus. A fourteen year/male presented with complain of gradually weakness of right sided limbs, severe headache, seizure and slurring of speech after two and half month of VP shunt placement for congenital hydrocephalus. CT scan head was done and it reported left CSDH with mass effect. Patient was managed with left parietal single burr-hole and CSDH evacuation.

Endoscopic Third Ventriculostomy and Simultaneous Tumor Biopsy in Pineal Region Tumors using the "Single Burr Hole" Technique: An Analysis of 34 Cases.

Background:Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature.Aim:The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique.Methods:The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a “single burr hole” technique from January 2012 to December 2019.Results:Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months.Conclusions:Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.

Single versus Double Burr Hole for Drainage of Chronic Subdural Hematoma: Randomized Controlled Study

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical emergencies. Most neurosurgeons currently drained CSDH through single or double burr holes; however, few studies have compared the 2 approaches to drainage. The aim of this study is to compare the recurrent rate following double and single burr hole for CSDH in our practice. This is a randomized controlled study from January 2015 to December 2019 in a neurosurgical unit in Kaduna, Nigeria. All patients with imaging diagnosis of subacute or chronic subdural hematoma who enrolled in the study had either a single or double burr hole. Patients were followed up for 6 months after surgery to assess for recurrence. Data were analyzed using SPSS version 25 for Windows. The Fisher exact test was performed to compare the 2 treatment groups. A 2-sided P value < 0.05 was considered statistically significant. A total of 192 patients were enrolled in the study with 99 in the single-burr hole group and 93 in the double burr-hole group. The overall recurrence rate in this study was 2.6%. The recurrence rate in the single arm was 3%, and in the double arm it was 2.2%. There was no statistically significant difference in recurrence between the 2 groups (P= 1.000). A single burr hole is as efficacious as a double burr hole in terms of relief of symptoms and recurrence, and it has a shorter duration of surgery.

Endoscopic Excision of Intraventricular Neurocysticercosis Cyst with an Angiocatheter: A Retrospective Analysis.

Introduction:An intraventricular cysticercus cyst is observed in 7%–30% patients of neurocysticercosis (NCC). Apart from causing arachnoiditis, intraventricular NCC (IVNCC) can cause sudden death due to acute episodes of hydrocephalus. Various treatment modalities available are external cerebrospinal fluid (CSF) diversion, microsurgical removal, and endoscopic management. There is no consensus regarding the optimal surgical treatment strategy. We are presenting our experience by doing a retrospective analysis of 26 patients having endoscopic removal of IVNCC with a rigid endoscope and angiocatheter.Aim:The aim of this study is to evaluate the results of neuroendoscopy in restoring the CSF pathway and removal of the cyst in patients of IVNCC.Materials and Methods:Retrospective analysis of clinical record and follow-up of 26 patients of IVNCC who were treated endoscopically between 2010 and 2018 was done. The diagnosis of IVNCC was made based on contrast enhanced magnetic resonance imaging of the brain. Transcranial endoscopy with 0° endoscope was performed through the frontal burr hole. Third ventriculostomy and removal of the cysticercus cyst with angiocatheter were the procedures done.Results:The success rate of intraventricular cyst excision, whether complete or partial, was 100% (14/14) in the third ventricular cyst, 62.5% (5/8) in the fourth ventricular cyst and 100% (4/4) in the lateral ventricular cyst. The overall success rate of cyst excision by endoscopy was 88.46%. The overall successful CSF flow pathway was established in 88.46% cases. The mean duration of follow-up was 44 months, and all the patients were found symptom free in the follow-up period.Conclusion:Neuroendoscopy, being a single burr hole technique successfully providing internal CSF diversion and cyst removal, is the treatment modality of choice for IVNCC.

Organized chronic subdural hematoma treated with middle meningeal artery embolization and small craniotomy: Two case reports

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

A minimally invasive approach for the treatment of isolated type intracranial dural arteriovenous fistula in a neurosurgical hybrid operating room

ObjectivesIsolated-type intracranial dural arteriovenous fistulas (DAVFs) could hinder the effective use of the transvenous approach. Direct trans-sinus embolization (dTSE) with craniotomy remains the treatment method for isolated-type DAVFs. We report our experience in using a neurosurgical hybrid operating room (NHOR) to treat cases of isolated-type DAVFs by dTSE using a single burr hole. Patients and methodsBetween April 2007 and March 2017, 189 DAVFs were treated by an endovascular procedure at our institution. Among these cases, 27 patients (14.3%) had isolated-type DAVF and 7 patients (3.7%) were treated by dTSE. The procedure accuracy and invasiveness of dTSE were compared with those of the transvenous embolization (TVE) group.The NHOR was equipped with a biplane angiography system and used to perform 3D rotational angiography (3DRA). The burr hole site was precisely determined by 3DRA. Only one burr hole was made to expose the target sinus and allow for direct puncture. The target sinus was occluded by using coils and liquid embolic material. ResultsThe NHOR allowed the accurate placement of the burr hole. Only a single burr hole and small skin incision (with minimal bleeding) were required for each dTSE case. The mean total contrast volume was significantly reduced in the dTSE group compared with that in the TVE group. Moreover, the dTSE group required shorter operation times and lower total radiation doses compared with the TVE group. ConclusionUsing dTSE could be performed with a single burr hole using a NHOR equipped with biplanar fluoroscopy. This approach is a minimally invasive and effective treatment for isolated-type DAVFs.

New tools in percutaneous minimally invasive chronic subdural hematomas evacuation

BackgroundIncidence of chronic subdural hematomas (cSDH) is expected to progressive rise in the next decades. There is no univocal indication of the approach to be used. Furthermore, there is no data about the efficacy of twist drill craniostomy (TDC) in hematomas with membranes. ObjectiveTo describe our modified technique for TDC in patients affected by cSDH with membranes and in treatment with antiplatelets. MethodsWe analyzed a group of 37 patients, affected by cSDH with membrane (type D laminar membrane and type G trabecular membrane according to Nakaguchi classification), treated with mushroom TDC using a modified technique. ResultsAfter surgery the average maximum thickness of the common postoperative liquoral subdural collection decreased from 18.8 to 6.21 mm. We documented one acute subdural hematoma (2.7%), asymptomatic and not treated, and one recurrence of cSDH (2.7%) after 2 months that needed re-intervention with single burr hole. ConclusionsWe presented a modified twist drill technique, characterized by the introduction of an application of a new device that optimizes both surgical results, clinical outcome and surgical procedure time. The presence of membrane type D and G does not affect the efficacy of drainage, that is negatively related to the presence of clots or acute hematoma. This modified technique is safe, fast, effective and represents a valid first line treatment of an unstable and unpredictable pathology such as cSDH. We suggest performing such technique on a larger patients’ cohort to further validate its effectiveness.