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Objectives:Chronic subdural hematomas (CSH) are generally the intracranial hematomas seen in the middle and elder aged group. The hemorrhage is formed as a result of stretched parasagittal bridge veins due to cerebral atrophy. The patients’ outcome that underwent surgery because of CSH was investigated in our clinic.Materials and Methods:Seventy-six operated CSH patients were included to the study in the University of Mersin, Faculty of Medicine between 2008 and 2016. The patients were divided into two groups with the drainage of burr-hole and craniotomy and evaluated in terms of clinical outcome retrospectively.Results:There are 52 male, 24 female patients with the mean age of 64.8 detected in the group. The most common initial symptom at admission is headache (52.6%). The head trauma was reported in 28 (36.8%) patients. The use of anticoagulant drug in 18 patients (23.6%) and also at least one comorbid disease in 38 patients (50%) were detected among CSH. The most common localization for the hematoma was left fronto parietooccipital in 26 patients (34.2%). Burr-hole in 65 (85.5%) patients, craniotomy in 11 (14.5%) patients were performed for the evacuation of the CSH. The mean thickness of all the hematomas was detected as 22.0 mm and the mean midline shift was measured as 6.8 mm. The complication rate was 26.6% in the group with burr-hole whereas it was 0.9% in the group with craniotomy. The mortality was 4.6% (3 cases) in the burr-hole group, 18.1% (2 cases) in the craniotomy group.Conclusion:The choice of surgical treatment modality was still controversy in the management of CSH that leads to morbidity and mortality which is most commonly seen in elder patient group. While the complication rate was being resulted as high in the group evacuated with burr-hole, the mortality was particularly high in the group with craniotomy.

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 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 Labbe 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 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.

There is controversy among neurosurgeons regarding whether irrigation or drainage is necessary for achieving a lower revision rate for the treatment of chronic subdural hematoma (CSDH) using burr-hole craniostomy (BHC). Therefore, we performed a meta-analysis of all available published reports. Multiple electronic health databases were searched to identify all studies published between 1989 and June 2012 that compared irrigation and drainage. Data were processed by using Review Manager 5.1.6. Effect sizes are expressed as pooled odds ratio (OR) estimates. Due to heterogeneity between studies, we used the random effect of the inverse variance weighted method to perform the meta-analysis. Thirteen published reports were selected for this meta-analysis. The comprehensive results indicated that there were no statistically significant differences in mortality or complication rates between drainage and no drainage (P > 0.05). Additionally, there were no differences in recurrence between irrigation and no irrigation (P > 0.05). However, the difference between drainage and no drainage in recurrence rate reached statistical significance (P < 0.01). The results from this meta-analysis suggest that burr-hole surgery with closed-system drainage can reduce the recurrence of CSDH; however, irrigation is not necessary for every patient.

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.

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/.

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 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 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 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"_blank" http://surgicalneurologyint.com/videogallery/lso-right-side/.

A best evidence topic in neurosurgery was written according to a structured protocol. The question addressed was: In patients undergoing craniostomy for the evacuation of chronic subdural haematoma, does the use of two burr-holes compared to one burr-hole improve clinical outcomes?A total of 238 papers were identified using the reported search protocol. Four of these articles represented the best evidence to answer the clinical question. The authors, date and country of publication, study type, patient group, outcomes and key results of these papers have been represented in a table.Three out of four studies showed that there was no significant difference in prevalence or rate of haematoma recurrence between two burr-hole craniostomy or one burr-hole craniostomy. Two studies demonstrated shorter hospital stay with two burr-hole craniostomy. Furthermore, one study showed increased rates of wound infection with one burr-hole craniostomy.Therefore, the clinical bottom line is that performing either two burr-hole craniostomy or one burr-hole craniostomy does not provide specific differences in patient outcome improvement following surgery for chronic subdural haematoma, however further research is required owing to the flawed methodology of existing studies.

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.