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Background: Trigeminal neuralgia, a common condition in clinical practice, often occurs due to vascular compression caused by aberrant or ectopic arterial or venous vessels. Microvascular decompression through a minimally invasive retrosigmoidal approach has shown high rates of pain control, low complication rates, and excellent therapeutic results., Objective: To describe the surgical technique and clinical outcomes in terms of pain relief after microvascular decompression of the trigeminal nerve through a minimally invasive retrosigmoidal parasterional burr-hole technique., Methods: A group of patients with trigeminal neuralgia refractory to medical management who underwent microvascular decompression were examined. The records of the patients were considered retrospectively (2016-2018), and the outcomes were considered based on the Visual Analogue Scale (VAS) and the Barrow Neurological Institute Pain Scale (BNIPS) added to a technical note of the surgical technique for a minimally invasive retrosigmoidal parasterional burr-hole., Results: Twenty-two patients were evaluated, and clinical assessment after surgical intervention showed a decrease in pain according to the VAS, resulting from an average preoperative state of 9.5 ± 0.37 to a postoperative condition of 1.32 ± 1.28, exhibiting statistically significant changes ( p < 0.0001, d = 9.356). On the other hand, in relation to the BNIPS scale, a decrease from an average preoperative status of 4.55 ± 0.25 to a postoperative status at 12 months of 1.73 ± 0.54 was also demonstrated, showing significant changes ( p < 0.0001, d = 3.960)., Conclusion: Microvascular decompression of the trigeminal nerve through a minimally invasive retrosigmoidal parasterional burr-hole is feasible and can be a safe and effective technique for the management of pain. However, further research employing larger sample sizes and longer follow-up periods is necessary.

Background  There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy. Methods  Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up. Statistical Analysis  Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p -value less than 0.05 was considered statistically significant. Results  The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p  < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted. Conclusion  Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters., Competing Interests: Conflict of Interest None declared., (Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Subdural hematoma is a common entity encountered by the neurosurgeon. The disease has acute, subacute, and chronic forms. Management of the disease changes according to the etiology of the lesion, yet the main goals are, as with most neurosurgical interventions, decompression of neural tissue and restoration of perfusion. Due to various forms and causes of the disease such as trauma, anticoagulant/antiaggregant use, arterial rupture, oncologic hemorrhages, intracranial hypotension, and idiopathic hemorrhages, several approaches for management have been documented in the literature. Herewith, we present various up-to-date management options for the disease., (© 2023. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Background: Postoperative pneumocephalus is associated with a higher risk of recurrence of chronic subdural hematoma (cSDH). However, there is no verified simple way to measure the pneumocephalus volume at the bedside for daily clinical use. The ABC/2 method was shown to be a simple and reliable technique to estimate volumes of intracranial lesions, such as intracranial hematomas. This study aims to evaluate the accuracy of the ABC/2 formula in estimating volumes of pneumocephalus, as compared to the gold standard with computer-assisted volumetric analysis., Methods: A total of 141 postoperative computed tomographic (CT) brain scans of cSDH patients with burr-hole drainage were analysed. Pneumocephalus volume was measured independently by both the ABC/2 formula and the computer-assisted volumetric measurement. For the computer-assisted measurement, the volume of the air was semiautomatically segmented and calculated by computer software. Linear regression was used to determine the correlation between the ABC/2 method and computer-assisted measurement., Results: The postoperative pneumocephalus volume after bilateral burr-hole drainage was significantly larger than that of unilateral burr-hole drainage (29.34 ml versus 12.21 ml, p < 0.001). The estimated volumes by the formula ABC/2 significantly correlated to the volumes as measured by the computer-assisted volumetric technique, with r = 0.992 (p < 0.001). The Pearson correlation coefficient is very close to 1, which signifies a very strong positive correlation, and it is statistically significant., Conclusions: An excellent correlation is observed between the ABC/2 method and the computer-assisted measurement. This study verified that the ABC/2 method is an accurate and simple "bedside" technique to estimate pneumocephalus volume., (© 2022. The Author(s).)

Introduction: Chronic subdural haematomas (cSDH) are one of the most common types of traumatic intracranial lesion. Burr-hole craniostomy followed by closed-system drainage has become the treatment of choice. However, there is no definitive indication as to the number of burr-holes needed. Our aim was to to assess clinical and radiological outcomes taking into account the number of burr-holes made., Material and Methods: A retrospective single-centre-study was performed including patients treated for cSDH by performing burr-hole craniostomy from 2012 to 2018. After collecting data regarding demographics, comorbidities, and clinical and radiological records, haematomas were grouped depending on the number of burr-holes made (Group 1: single burr-hole; Group 2: double burr-holes). Clinical and radiological outcomes were statistically compared between groups, as well as the main complications., Results: After collecting 171 patients, 205 cSDHs were analysed. 173 were treated with a single burr-hole (we called these Group 1) and 32 with double burr-holes (Group 2). No differences in preoperative characteristics were found between the groups, except for diabetes mellitus and previous antiplatelet/anticoagulation treatment. No radiological differences were found regarding haematoma volume (p = 0.7) or thickness (p = 0.3). Surgical site infection (p = 0.13), recurrence (p = 0.6), acute rebleeding (p = 0.25) and mortality (p = 0.94) were assessed without evidencing statistically significant differences. At the time of hospital discharge, most patients showed a remarkable clinical improvement, regardless of the number of burr-holes made (p = 0.7)., Conclusions: This study suggests that cSDH can be efficiently evacuated by a single burr-hole craniostomy, a less invasive and shorter surgical procedure with quite good clinical outcomes and a low rate of complications.

Objective: Chronic subdural hematoma (CSH) is a common neurosurgical disease among elderly population with concomitant degenerative neurological disorders. This is a retrospective series-control analysis of prospectively collected data, aiming to show advantages and indications of a minimally invasive, percutaneous drainage system for CSH., Patients and Methods: We retrospectively analyse the clinical and radiological data of a minimally invasive, percutaneous draining system (Integra ™) used in fifteen patients (Group A; mean age: 75.7) with CSH, and compare them with those obtained from two retrospective series of patients: the first one (Group B 15 patients, mean age 77.1) treated with standard, single-burr hole technique for subdural drainage under general anaesthesia; the second one (Group C 15 patients, mean age 76.4) treated with standard, single-burr hole technique for subdural drainage under local anaesthesia and mild sedation. All The percutaneous procedures (Group A) were performed under local anaesthesia., Results: Mean follow-up was 10.9 (range 3-14), 18.2 (range 10-29) and 15.2 (range 8-28) months in Group A, B and C respectively. Three of 15 and in Group B experienced a worsening of pre-existing neurodegenerative disorders after general anaesthesia. One patient in group C suffering from Parkinson's disease experienced a worsening of gait disturbances. Post-operative CT scans were performed at 48 h and 21 days after the operation. An early post-operative CT-scan, obtained immediately after surgical procedure, was performed in all Group A patients. No differences in CSH evacuation were observed comparing the three groups. Two recurrent hematomas, one in group A and one in group B, required revision. Post-operative hospitalization was similar (5.1 vs 5.7 vs 5.6 days, respectively, in group A, B and C) but analgesics use was lower in Group A., Conclusion: Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for a minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: In this video abstract, we present a one burr-hole craniotomy for a modified presigmoid approach developed in Helsinki Neurosurgery to access the space extended to both middle and posterior fossa. Thus, indications for this approach are lesions that extend to both middle and posterior fossa, petroclival tumors, basilar tip aneurysms located extremely low below the posterior clinoid process, trunk basilar aneurysms, and bypass procedures from the P2 segment of the posterior cerebral artery. The procedure is composed by three stages: a temporal and presigmoid craniotomy, a partial petromastoidectomy, and the dura opening with section of the superior petrosal sinus (SPS) and the tentorium. Even though some risks related to the opening of the mastoid cells or cut of the SPS may exist, benefits of this optimized craniotomy are higher compared with the complications., Case Description: The patient with a giant petroclival meningioma is placed in park bench position and spinal drainage is inserted. Skin incision starts in front of the ear curve going to 1 inch behind the mastoid line. Strong retraction with hooks keeps a clean space for the craniotomy. Hemostatic Raney clips are placed at the superior border of the skin flap. A burr-hole is made at the most cranial part of the temporal bone. After the detachment of the dura with long flexible blunt dissectors, the craniotomy is performed to expose the sigmoid sinus, the SPS and the dura of the inferior temporal lobe, and the floor of the middle fossa. Aiming to access the posterior fossa by a presigmoid route, a partial petromastoidectomy is performed preserving the semicircular canals. Few drill holes are made for tack-up sutures. Once we properly reach the dura of the middle and posterior fossa, dura of the temporal lobe and later, the presigmoid dura are opened joining at the level of the SPS. The SPS, which is running over the petrous bone between the posterior and the middle fossa, is coagulated, ligated, and cut. After SPS is sectioned, the tentorium is cut anterior to the drainage of vein of Labbé and posterior to the deep tentorial insertion of the fourth nerve. Finally, special care should be taken to seal the opened mastoid cells with muscle and glue, and for the hermetic dura closure using pericranium or temporal muscle aponeurosis., Conclusion: The described one burr-hole craniotomy may represent the more efficient approach for the management of the deep and hardly accessible lesions extended to both middle and posterior fossa., Videolink: http://surgicalneurologyint.com/videogallery/presigmoid-approach-craniotomy-lt.

Background: In this video abstract, we present a one burr-hole craniotomy for the posterior interhemispheric approach developed in Helsinki Neurosurgery to access posteriorly the medial surface of cerebral hemispheres, falx cerebri, and deep midline cerebrovascular structures. Therefore, preoperative imaging is essential to achieve an optimal operative corridor for a safest and more effcient approach., Case Description: The patient with a papillary tumor of the pineal region is placed in sitting position. A midline single-layer skin incision is made in front of the superior sagittal sinus. Strong retraction maintains a clean space for craniotomy. Aiming to reduce the risk of sinus transgression or cortical veins damaging in the eloquent frontal-parietal area, a burr-hole is made over the superior sagittal sinus at the anterior border of the bone flap and the bone is detached from the dura posteriorly with blunt dissectors. Thus, proximal detachment of the dura under some visual control remains safe. A long blunt flexible dissector is used during this stage in case of elderly patients with an adherent dura. Craniotomy around the superior sagittal sinus is performed to expose 2-3 cm of the dura lateral to the sagittal sinus according to the exact location of the lesion. Moreover, craniotomy extends slightly over the contralateral side to allow some retraction of the sagittal sinus. Two cuts, from both sites of the burr-hole, are joined along the posterior midline. A few drill holes are made for tack-up sutures. Finally, a hemostatic agent covers the sagittal sinus and a sinus-based dura opening is performed under the microscope., Conclusion: The described one burr-hole craniotomy may represent a more efficient manner for performing a posterior interhemispheric approach., Videolink: http://surgicalneurologyint.com/videogallery/posterior-interhemispheric-approach.

Background: In this video-abstract, we present one burr-hole craniotomy for the standard suboccipital midline approach developed in Helsinki neurosurgery for the microsurgical management of forth ventricle lesions, distal posterior inferior cerebellar artery aneurysms, and tumoral and vascular lesions of the vermis, cisterna magna region, and posterior brainstem as well., Case Description: We prefer to position the patient in sitting praying position. A midline straight single-layer incision starts on the inion and extends caudally toward the level of C2. The muscles are divided with diathermia along the occipital bone. Three curved retractors, two upward and one downward, provide a wide clean space for the craniotomy. Finger palpation and blunt dissection with cottonoids balls provide identification of the foramen magnum and the spinous process of C1. A burr-hole is made 1 cm lateral and below the level of the transverse sinus. After the detachment of the dura with a curved angled dissector, two cuts from both sites of the burr-hole are made with the craniotome. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (yasargil dissector) is used for the detachment of the bone from the dura. A craniotomy around the midline overlying the occipital sinus and the falx cerebelli is performed to expose medial aspects of cerebellar tonsils, the medulla oblongata, and the occipital sinus. Special care should be taken to avoid damaging the vertebral artery and the epidural sinuses running at the foramen magnum. A few drill holes are made for tack-up sutures. After a craniocervical-based opening of the dura, the fourth ventricle is accessed directly by telovelar route., Conclusion: The described one burr-hole craniotomy may represent the more efficient manner for performing the suboccipital midline approach to the fourth ventricle., Videolink: http://surgicalneurologyint.com/videogallery/suboccipital-midline-approach/.

Objective: To explore the therapeutic effect of burr-hole operation combined with dural inversion and temporalis-periosteal synangiosis for ischemic moyamoya disease of adults. Methods: The burr-hole operation combined with dural inversion and temporalis-periosteal synangiosis was performed on 21 adults with ischemic moyamoya disease since January 2013 in the second hospital of Shandong university.All of the patients were followed up for 3 months to 3 years.Digital subtraction angiogram (DSA) reexamination was performed and the cerebral MR perfusion imaging (PWI) was used to observe the perfusion of cerebral ischemic area before and after operation quantificationally, and the KPS scores before and after the surgery were analysed by the statistics.The clinical symptoms of the 21 patients gradually improved after the operation, there was statistical significance by paired t test of the KPS scores ( P <0.001). Results: 19 patients were reexamined by DSA and PWI.The DSA results revealed there was apparent neovascularization in 65 burr-holes of total 72 holes , mainly came from the middle meningeal artery and superficial artery, and there was neovascularization in 33 burr-holes of total 35 holes whose arachnoid was completed, there was no statistical significance by χ(2) test ( P >0.05). The revascularization of the ischemic cerebral tissue was obtained through the PWI.The postoperative complications included 1 case of subdural hematoma, 3 cases of postoperative temporary neurological deficits. Conclusion: The burr-hole operation combined with dural inversion and temporalis-periosteal synangiosis was effective, the MR perfusion imaging could assessment the effect exactly, there was no significant difference of neovascularization whether or not opening the arachnoid.

Background: In this video-abstract, we present a one burr-hole craniotomy for the enough lateral approach (ELA) to the foramen magnum developed in Helsinki Neurosurgery, a less invasive variant of the classical far lateral approach. ELA does not require the resection of the occipital condyle nor the exposure of the extracranial/intraosseal course of the lower cranial nerves. The vertebral artery is not transposed and the sigmoid sinus is not skeletonized. ELA allow us to access lesions that are close to the level of the foramen magnum (less than 10 mm). In this regard, low-lying vertebral aneurysms, foramen magnum meningiomas, or low brainstem cavernomas and intrinsic tumors are our common indications for this approach., Case Description: The patient with a foramen magnum meningioma is placed in park bench position with slight backward rotation and elevation of the upper body to maintain the head around 20 cm above the cardiac level. The correct positioning of the head requires slight forward flexion, contralateral rotation, and contralateral tilt to open the angle with the upper shoulder. Under microscopic vision, a straight incision is made behind the mastoid process running between the zygomatic line and 4-5 cm below to the level of the mastoid process. The suboccipital muscles are split with electrocoagulation while the vertebral artery is recognized by digital palpation. Blunt dissection with cotton balls is performed at the occipitocervical junction. Strong retraction maintains a clean space for the craniotomy. A single burr-hole is placed at the posterior border of the craniotomy, and a small 3 × 4 cm craniotomy is performed over the anterior border of the intradural origin of the vertebral artery. The anterior lateral border of the craniotomy is reached under visual control using a diamond drill. In this regard, one more burr hole opposite to the first one would be a tiring and difficult procedure deep inside the lateral margin of the craniotomy. The dura is opened based on the sigmoid sinus and cerebrospinal fluid is released. Finally, under high microscopic magnification, the lesion is properly removed., Conclusion: The described procedure may represent a more efficient lateral approach to the foramen magnum., Videolink: http://surgicalneurologyint.com/videogallery/enough-lateral-approach-for-the-foramen-magnum/.

Background: In this video-abstract, we present a one burr-hole craniotomy for the upper retrosigmoid approach developed in Helsinki Neurosurgery to access the lateral cerebellar hemisphere, the cerebellopontine angle, and lateral skull base (e.g. including the posterior petrous bone). This approach may be utilized to manage tumors of the lateral posterior fossa and to perform microvascular cranial nerve decompression of the V or VII cranial nerves. The upper portion of the vertebral-posterior cerebral artery complex, and the anterior inferior cerebellar artery may also be accessed with this technique. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with a very minimal variation., Case Description: The patient with an unsuspected right cerebellopontine angle metastasis from a lung cancer is placed in the park bench position. Spinal drainage is inserted to release 50-100 ml of cerebrospinal fluid. The head and upper torso are elevated so that the head is about 20 cm above the heart level. A single-layer skin incision is made about one inch behind the mastoid process; the exact cranial to caudal location of the incision varies depending on how high or low one has to be from the foramen magnum and locus of pathology. The junction of the sigmoid and the transverse sinus is usually located just caudal to the zygomatic line, between the zygoma and the external occipital protuberance, and posterior to the mastoid line that is running caudally through the tip of the mastoid process. Dissection with curved retractors creates a clean space for the craniotomy. First, a burr-hole is made at the posterior border of the bone flap. Two curved cuts are made towards the mastoid process, allowing the sigmoid sinus to be partially exposed. The bone is cracked after thinning the anterior border of the craniotomy. A few drill holes are then made for tacking-up sutures. Finally, a sinus-based dura opening is performed under the microscope., Conclusion: Here, we described a one burr-hole craniotomy that provides an excellent approach to retrosigmoid lesions., Videolink: http://surgicalneurologyint.com/videogallery/retrosigmoid-approach.

Background: In this video abstract, we present a one burr-hole craniotomy for the standard supracerebellar infratentorial (SCIT) paramedian approach developed in Helsinki Neurosurgery for the microsurgical management of pineal region lesions, tentorial meningiomas, as well as arteriovenous malformations, aneurysms, and intrinsic tumors of the superior surface of the cerebellum. In this regard, the use of praying sitting position in Helsinki Neurosurgery, which is a more ergonomic variant of the classic sitting position, offers several advantages such as lower intracranial pressure, good venous outflow, gravitational retraction, and straight anatomical orientation., Case Description: The patient is placed in sitting praying position. A straight single-layer incision is made 2-3 cm lateral from the midline, starting about 1 inch cranial from the inion and extending caudally toward the foramen magnum. Curved retractors provide a wide clean space for craniotomy. A burr-hole is made above the transverse sinus, which may be identified by its anatomic relation with superior muscle insertion line on the occipital bone. After detachment of the dura with blunt dissectors, a craniotomy around the transverse sinus and continuing to the confluens sinuum is performed to expose about 3 cm of the dura below the level of the transverse sinus. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (Yasargil dissector) is used for the detachment of the bone from the dura. A few drill holes are made for tack-up sutures. Finally, a hemostatic agent covers the transverse sinus and a sinus-based dura opening is performed under the microscope., Conclusion: One burr-hole craniotomy for an SCIT paramedian approach may represent the more efficient procedure for approaching the pineal region, inferior surface of the tentorium, and the superior surface of the cerebellum as well., Videolink: http://surgicalneurologyint.com/videogallery/paramedian-subocciptal-approach.

Background: In this video-abstract, we present the Helsinki Neurosurgery one burr-hole craniotomy standard subtemporal approach to the floor of the middle fossa and the interpeduncular space. This procedure facilitates access to the multiple structures; the basilar artery bifurcation, the superior cerebellar artery, or the P1-P2 segments of the posterior cerebral artery, and lesions located around the posterior clinoid process/less than 10 mm above it. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with very minimal variation., Case Description: The patient with a basilar artery bifurcation aneurysm is placed in park bench position. A spinal drain is inserted to release 50-100 ml of cerebrospinal fluid. Next, the skin incision starts in front of the tragus above the earlobe, crossing the zygomatic line. Inferior retraction for the craniotomy is provided by hooks and hemostatic Raney clips placed at the superior border of the skin flap. The zygomatic line represents the anatomical landmark of the floor of the middle fossa. A burr-hole is made at the most cranial border of the bone flap. After the detachment of the dura with long flexible blunt dissectors, a craniotomy is performed to expose the dura of the inferior temporal lobe. A few drill holes are made for tacking-up sutures. The dural opening is then performed based on the zygomatic line. Cutting and opening of the tentorium runs posterior to the tentorial insertion of the fourth nerve., Conclusion: The described one burr-hole craniotomy offers a more efficient subtemporal approach., Videolink: http://surgicalneurologyint.com/videogallery/subtemporal-approach-unedited/.

Background: In this video abstract, we present a one burr-hole craniotomy for the standard lateral supraorbital approach (LSO) developed by Helsinki Neurosurgery. This is a more aesthetic variant of the classic pterional approach. Presently, the LSO approach is most commonly used at our institution. With the LSO technique, the temporal muscle is just minimally opened close to its superior insertion. Posterior and temporal extension of the craniotomy, furthermore, allows adequate access to the anterior skull base, the sellar and suprasellar regions, the middle cranial fossa, the anterior portion of the Sylvian fissure, and the distal Sylvian fissure. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with a very minimal variation., Case Description: The patient with an unruptured anterior communicating artery aneurysm is placed in supine position with the head elevated 30 cm from the level of the heart. The head position is determined by the specific location of the lesion. A curved frontotemporal skin incision is made behind the hairline which stops 2-3 cm above the zygoma. Anterior retraction and hemostatic Raney clips placed at the posterior border of the skin flap maintain a clean space for the craniotomy. A burr-hole is made at the level of the temporal line in the frontal bone. After the dura is detached with blunt dissection, a craniotomy is performed to reach the anterior skull base. A few drill holes are made for tack-up sutures and the dura is opened using conventional techniques. The anterior skull base, sellar/suprasellar regions, and select lesions located in the upper basilar region may be accessed through this subfrontal approach. Middle cerebral artery aneurysms and lesions located along the sylvian fissure or in the middle fossas may also be approached with this exposure, but would require further opening of the proximal sylvian fissure., Conclusion: There we described the LSO one burr-hole craniotomy technique that may represent a more efficient procedure for performing LSO., Videolink: "http://surgicalneurologyint.com/videogallery/lso-right-side/"\t"&#95;blank" http://surgicalneurologyint.com/videogallery/lso-right-side/.

Background: In this video-abstract, we present a one burr-hole craniotomy for the anterior interhemispheric approach developed in Helsinki Neurosurgery to access the medial surface of cerebral hemispheres, the falx cerebri, the distal segment of the anterior cerebral artery, the corpus callosum, the third ventricle, and the lateral ventricles. Therefore, preoperative imaging is essential to achieve an optimal operative corridor for safest and more effcient approach., Case Description: The patient with a no ruptured right pericallosal aneurysm is placed in semi-sitting position. A midline single-layer curved skin incision is made behind the hairline with more extension to the side of the planned bone flap. Strong retraction with hooks keeps a clean space for craniotomy. Hemostatic Raney clips are placed at the posterior border of the wound. A burr-hole is made over the superior sagittal sinus at the posterior border of the bone flap. The bone is detached from the dura anteriorly with blunt dissectors. Thus, we avoid harming the superior cerebral veins distributed at the posterior frontal area. After the detachment of the dura, a craniotomy around the superior sagittal sinus is performed to expose 2-3 cm of the dura lateral to the sagittal sinus. Moreover, the craniotomy extends slightly over the contralateral side to allow some retraction of the sagittal sinus. Two cuts, from both sites of the burr-hole, are joined along the anterior midline by thinning the bone with craniotome blade without the footplate. A few drill holes are made for tack-up sutures. The bone is cracked along the thinned midline. Finally, a hemostatic agent covers the sagittal sinus and a sinus-based dura opening is performed under the microscope., Conclusion: The described one burr-hole craniotomy may represent a more efficient manner for performing an anterior interhemispheric approach., Videolink: http://surgicalneurologyint.com/videogallery/anterior-interhemispheric-approach/.

Background: Factors determining the recurrence of chronic subdural hematomas (CSDHs) are not clear. Whether opening the so-called internal hematoma membrane is useful has not been investigated., Objective: To investigate whether splitting the inner hematoma membrane influences the recurrence rate in patients undergoing burr-hole craniotomy for CSDH., Methods: Fifty-two awake patients undergoing surgery for 57 CSDHs were prospectively randomized to either partial opening of the inner hematoma membrane (group A) or not (group B) after enlarged burr-hole craniotomy and hematoma evacuation. Drainage was left in situ for several days postoperatively. Groups were comparable with regard to demographic, clinical, and imaging variables. Outcome was assessed after 3-6 weeks for the combined outcome variable of reoperation or residual hematoma of one third or more of the original hematoma thickness., Results: Fourteen patients underwent reoperation for clinical deterioration or residual hematoma during follow-up (n = 6 in group A, 21%; n = 8 in group B, 28 %) (P = 0.537). Residual hematoma of ≥ one third not requiring surgery was present in 7 patients in group A (25%) and 10 patients in group B (36%) (P = 0.383). The overall cumulative failure rate (reoperation or hematoma thickness ≥ one third) was 13/28 (46%) in group A and 18/28 in group B (P = 0.178; relative risk, 0.722 [95% confidence interval, 0.445-1.172]; absolute risk reduction -16% [95% confidence interval, -38% to 8%])., Conclusions: Opening the internal hematoma membrane does not alter the rate of patients requiring revision surgery and the number of patients showing a marked residual hematoma 6 weeks after evacuation of a CSDH., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine whether the use of a subdural drain after burr-hole evacuation of a chronic subdural hematoma is safe and effective in preventing recurrence and subsequent operations, and as such improving functional outcomes., Methods: The literature search included the following databases: PubMed, the National Institutes of Health/National Library of Medicine, Clinical Trials Registry, CENTRAL (The Cochrane Library), EMBASE, and LILACS. The search was performed in June 2013, and did not have restrictions or filters with regard to language or year of publication. Methodologic quality was assessed through the Jadad's scale. Primary outcomes were recurrence and reoperation rates. Secondary outcomes were functional outcome, mortality, and postoperative complications. Results were presented as pooled Mantel-Haenszel relative risks (RR), with 95% confidence intervals (95% CI)., Results: A total of 7 randomized controlled trials were analyzed. Three studies were classified as high methodologic quality and four as low quality. Pooled RR were symptomatic recurrence (RR 0.51; 95% CI 0.36-0.75), reoperation (RR 0.5; 95% CI 0.34-0.74), poor functional outcome (RR 0.61, 95% CI 0.39-0.98), mortality (RR 0.67, 95% CI 0.37-1.22), and postoperative complications (RR 1.28, 95% CI 0.78-2.11). There was no statistically significant heterogeneity within the outcomes., Conclusions: The meta-analysis demonstrates that the insertion of a subdural drain was associated with a statistically significant reduction in the risk of symptomatic recurrence and the requirement for further surgical intervention of chronic subdural hematoma after surgical evacuation. Furthermore, it was associated with statistically significant improvements in both short-term and long-term functional outcome., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To analyze the clinical data and surgical results from symptomatic chronic subdural hematoma (CSDH) patients who underwent burr-hole drainage (BHD) at the maximal thickness area and twist-drill craniostomy (TDC) at the precoronal point., Methods: We analyzed data from 65 symptomatic CSDH patients who underwent TDC at the pre-coronal point or BHD at the maximal thickness area. For TDC, we defined the pre-coronal point to be 1 cm anterior to the coronal suture at the level of the superior temporal line. TDC was performed in patients with CSDH that extended beyond the coronal suture, as confirmed by preoperative CT scans. Medical records, radiological findings, and clinical performance were reviewed and analyzed., Results: Of the 65 CSDH patients, 13/17 (76.4%) with BHD and 42/48 (87.5%) with TDC showed improved clinical performance and radiological findings after surgery. Catheter failure was seen in 1/48 (2.4%) cases of TDC. Five patients (29.4%) in the BHD group and four patients (8.33%) in the TDC group underwent reoperations due to remaining hematomas, and they improved with a second operation, BHD or TDC., Conclusion: Both BHD at the maximal thickness area and TDC at the pre-coronal point are safe and effective drainage methods for symptomatic CSDHs with reasonable indications.

Introduction: Several studies have suggested the possible influence of postoperative bed header position on the risk of symptomatic recurrences and medical complications in patients who have been intervened due chronic subdural haematomas. Nevertheless, this hypothesis has not been assessed by a meta-analysis., Methods: All randomised controlled trials analysing symptomatic recurrence rates in patients who underwent burr-hole drainage of chronic subdural haematomas, describing postoperative bed header positioning, were included. The primary outcome was risk of recurrence and the secondary outcome were the risks of reoperation and medical complications. Results were presented as pooled relative risks, with 95% confidence intervals., Results: A total of 4 controlled studies were included. Pooled relative risks were: symptomatic recurrences 0.51 ([95% CI: 0.22-1.16]; P=.11), reoperations, 1.07 ([95% CI: 0.42-2.69]; P=.89) and medical complications, 1.15 ([95% CI: 0.7-1.91]; P=.58). No statistically significant heterogeneity was found in any of the analyses., Conclusion: There were no differences regarding frequency of symptomatic recurrences, reoperations or medical complications in patients who were maintained in a flat position compared with those whose bed header was elevated during the postoperative course. Despite there being consistency between the results, there is a potential risk of bias; thus proscribing definitive recommendations until studies with higher methodological quality are available., (Copyright © 2013 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.)