Acta Neurochir (2014) 156:981987

DOI 10.1007/s00701-014-2042-8

REVIEW ARTICLE - BRAIN INJURY

Mini-craniotomy as the primary surgical intervention

for the treatment of chronic subdural hematomaa retrospective
analysis
Jorn Van Der Veken & Johnny Duerinck & Ronald Buyl &
Katrijn Van Rompaey & Patrick Herregodts &
Jean DHaens

Received: 21 November 2013 / Accepted: 16 February 2014 / Published online: 11 March 2014
# Springer-Verlag Wien 2014

Abstract
Background The incidence of chronic subdural hematoma
(CSDH) is increasing, but optimal treatment remains controversial. Recent meta-analyses suggest burr hole (BH) drainage
is the best treatment because it provides optimal balance
between recurrence and morbidity. Mini-craniotomy may offer supplementary technical advantages while maintaining
equal or better outcomes. This study investigates the
outcome of mini-craniotomy as the sole treatment in
patients with CSDH.
Method We analyzed all patients operated on for CSDH with
mini-craniotomy in our neurosurgical center between 2005
2010. Baseline patient characteristics (age, sex, comorbidities,
imaging characteristics, known risk factors for development
of CSDH and neurological examination at presentation) and
outcomes (mortality, complications, recurrence and neurological examination at discharge) were recorded.
Results One hundred twenty-six adult patients were included,
mean age was 73.9 (range 18 to 95) years old, and the sex ratio
(M:F) was 2:1. Eighty-four percent of the patients showed
clinical improvement at discharge, as shown by a decrease in
the Markwalder score postoperatively (with 57 % Markwalder

0 and 23 % Markwalder 1). Recurrence rate was 8.7 %.

Overall complication rate was 34.1 % (27.8 % medical complications and 6.3 % surgical complications). In-hospital mortality was 13.5 % (8.7 % due to pulmonary infections and
1.6 % to surgical complications). Preoperative Markwalder
grade correlated significantly with complication rate, as did
the presence of a neurodegenerative disease (p=0.018). Factors significantly related to mortality in univariate analysis
were arterial hypertension (p=0.038), heart failure (p=0.02),
renal failure (p=0.017), neurodegenerative disease (p=0.001),
cerebrovascular accident (p=0.008) and coagulopathy (p=
0.019). Multivariate analysis was not able to confirm any
significant relationship.
Conclusion This is the first published series of CSDH in
which all consecutive patients were operated on by minicraniotomy. The invasiveness and complication rate of minicraniotomy are equal to those of burr hole treatment, but
visualization is superior, resulting in lower recurrences. A
randomized controlled trial is indicated to identify the best
surgical strategy for the treatment of CSDH.

Portions of this work were presented in poster form at the Annual

Scientific Meeting of the Belgian Society of Neurosurgery in Ghent,
Belgium

Introduction

J. Van Der Veken (*) : J. Duerinck : K. Van Rompaey :

P. Herregodts : J. DHaens
Department of Neurosurgery, Universitair Ziekenhuis Brussel,
Brussels, Belgium
e-mail: jpvdveke@vub.ac.be
R. Buyl
Department of Biostatistics and Medical Informatics, Vrije
Universiteit Brussel, Brussels, Belgium

Keywords Chronic subdural hematoma . Mini-craniotomy

Chronic subdural hematoma (CSDH) is one of the most common pathologies encountered by neurosurgeons. The incidence
of CSDH increases proportionally with age, with a recent
estimated incidence of 20.6/100,000/year for patients between
70 and 79 years old and 127.1/100,000/year in the over 80 age
group [11]. Older studies reported incidences of only 7.35-8.2 /
100,000/year in the age group older than 65 years [2, 8]. Due to
the increasing average age of the Western population and the

982

fact that CSDH mainly affects the elderly, a further increase in

incidence is expected. This emphasizes the necessity of guidelines concerning optimal treatment.
Even though it is one of the most frequently encountered
cranial pathologies in neurosurgical practice, much controversy still remains regarding the best surgical treatment. Published results are highly variable, with recurrence rates ranging from 0.35 % to 60 % [22, 31]. Complication rates from
0 % to 34 % have been reported while surgical mortality in
studies ranges from 0 % to 24 % [17, 21, 24, 28].
Recent meta-analyses propose burr hole (BH) drainage as
the most efficient choice because it provides the best balance
between recurrence and morbidity [14, 23, 29]. It should be
noted, however, that the pooled data used for these metaanalyses are very heterogeneous and often biased toward the
most commonly used treatment modality. The meta-analyses
investigating the craniotomy technique are mostly based on
small populations and are often biased since they are not controlled or randomized [7, 14, 30]. Moreover, most studies and
meta-analyses do not make the distinction between large craniotomy and mini-craniotomy, where the diameter of the bone
flap remains limited to 3-4 cm [12]. Mini-craniotomy is less
often used nowadays, probably as a result of these publications.
To our knowledge, there are no published surgical series
where mini-craniotomy is used as the only technique for the
treatment of CSDH in adult patients. This technique offers
theoretical advantages over other treatment options, such as a
better visualization of the subdural space and the possibility to
widely open membranes, while the claimed disadvantages of
longer operating time and higher complication rate could
prove to be less prominent when only considering minicraniotomy and disregarding large craniotomy.

Methods
Patient selection and data
In our neurosurgical center, mini-craniotomy performed under
general anesthesia is the preferred technique for treatment of
CSDH. We retrospectively analyzed all consecutive patients
operated on for CSDH in our center between January 2005
and December 2010 and compared these results with those in
the literature. Data were obtained by reviewing neurosurgical
logbooks and patient files at the University Hospital UZ
Brussel, Brussels, Belgium.
Baseline patient characteristics such as age, sex, comorbidities, known risk factors for development of CSDH (use of
anticoagulants or antiplatelet drugs, presence of a coagulation
disorder, a ventriculo-peritoneal shunt and a history of alcohol
abuse) and neurological examination at presentation were
registered. Comorbidities that were listed were arterial hypertension (AHT), diabetes mellitus (DM), heart failure (HF),

Acta Neurochir (2014) 156:981987

renal failure (RF), chronic obstructive pulmonary disease

(COPD), the presence of a neurodegenerative disease (ND),
hyperlipidemia and a prior cerebrovascular accident (CVA).
Neurodegenerative diseases consisted of dementia and
Parkinsons disease. History of alcohol abuse was defined as
the consumption of four or more alcoholic beverages per day.
Pre- and postoperative CT and/or MRI images were analyzed. The type of CSDH was classified as either mixed
density, homogeneous and isodense to the brain or homogeneous and hypodense to the brain. The neurologic performance of the patients was evaluated pre- and postoperatively
using the Markwalder Neurological Grading System, which
is the most commonly used neurological grading system for
CSDH [16] (Fig. 1).
Clinical and radiological status of the patients after treatment were evaluated upon discharge from the hospital. Date
of latest follow-up was recorded. Uniform criteria were used
to define mortality, complications and recurrence rate. Mortality was defined as death reported between surgery and
discharge from the hospital. Complications included all medical and surgical complications other than recurrence or mortality during hospitalization. Surgical complication was a
complication directly related to the surgical intervention. Recurrence was defined as reoperation for an ipsilateral symptomatic CSDH within 6 months after the previous surgical
evacuation (reoperation rate). Hospital stay was defined as the
duration from the initial operation to discharge. In reoperated
cases, the duration of hospitalization from the second operation onwards was also added to the hospital stay.
Surgical technique
In the literature, craniotomy is defined as an opening of the
skull with a diameter larger than 30 mm and with repositioning of the bone flap at the end of the intervention. In
mini-craniotomy, the diameter of the bone flap remains limited to 3-4 cm. Openings with a diameter between 5 and 30 mm
are called burr holes (BH), those smaller than 5 mm twist drill
craniostomy [30].
All surgeries in this series were performed under general
anesthesia. The small osteoplastic craniotomy was performed
in most cases using a trephine. In ten patients, the minicraniotomy was performed by connecting one or two burr
holes with the craniotome. After the craniotomy the dura

Fig. 1 Markwalder grading score

Acta Neurochir (2014) 156:981987

had been incised, the outer membrane of the hematoma coagulated and was maximally opened. Following the initial removal of the hematoma or remaining clots, the subdural space
was irrigated rigorously with physiological saline water until
the drained fluid became clear. A subdural Jackson Pratt
drainage catheter was then placed, the bone flap replaced, and
the skin closed. The Jackson-Pratt catheter was left in situ for a
minimum of 24 h and a maximum of 96 h, its removal depending on the amount of drained volume of blood and the result of
postoperative CT or MRI imaging. In case of bilateral hematomas, the patient was included in the study as one case, and both
sides were treated simultaneously using the same technique.

Statistical analysis
Variables considered in the statistical analysis included sex,
age, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, heart failure, renal failure, neurodegenerative
disease, parkinsonism, cerebrovascular accidents, ethylism,
antiplatelet therapy, anticoagulant therapy, coagulopathy and
hematoma characteristics.
For statistical analysis, IBM SPSS (v. 20) software was
used. We performed a univariate analysis to assess the relationship between each variable and the outcome (mortality,
recurrence, complications) by applying the Mann-Whitney U
test (for non-categorical) and the chi-square test (for categorical variables). All significant univariate results were then
tested in a multivariate logistic regression model.
All tests were performed using a 5 % significance level.

Results
Patient characteristics
During the 6-year evaluation period, 131 patients underwent
surgery for CSDH. Five patients were excluded from the
analysis because they were younger than 18 years. Eightysix (68 %) patients were male, and 40 (32 %) were female.
Average age was 73.4 years old, 73.2 in the male group and
75.3 in the female group, with a range of 18 to 95 years old.
Age and gender distributions of the patient population are
illustrated in Fig. 2.
104 out of 126 (84.6 %) patients had at least one medical
comorbidity (see "Materials and methods" for listing). In 75
patients (59 %), there was a history of trauma, and 4 patients
had a ventriculo-peritoneal shunt. Almost half of the patients
(56/126; 44 %) were treated with anticoagulants (n=20) or
antiplatelet agents (n=36). Seven patients (5 %) had a coagulopathy. Eighteen patients (14 %) had a history of chronic
alcohol abuse. Thirty-six out of the 75 (48 %) patients who
had a history of trauma were on anticoagulant medication or

983

Fig. 2 Age and gender distribution of the patient population

antiplatelet agents versus 20 out of 47 (42 %) patients where

no clear cause could be found (Table 1).
Symptoms and signs at presentation are shown in Fig. 3.
The most frequent clinical finding at presentation was motor
deficit in 36 patients (28 %), ranging from focal limb weakness to hemiplegia, followed by an altered level of consciousness in 33 patients (26 %), headache in 23 (18 %), dysphasia
in 15 (12 %), gait disturbance in 14 (11 %) and seizures in 5
(4 %). The majority of patients presented with a combination
of these symptoms. In the group of patients with altered level
of consciousness, 7 were comatose (Markwalder grade 4).
The CSDH was left hemispheric in 62 patients (49 %),
right hemispheric in 38 patients (30 %) and bilateral in 26
patients (21 %). The CT density was mixed in 87 patients
(69 %). In 16 patients it was homogeneously hypodense
Table 1 Characteristics of different outcome groups
Characteristics

Recurrence

Complication

Mortal

Mean age
Number of patients
Male/female
Anticoagulant
Antiplatelet
Coagulopathy

75.0
11 (8.7 %)
9/2
2 (18.2 %)
3 (27.3 %)
0

74.5
43 (34.1 %)
27/14
9 (20.9 %)
17 (39.5 %)
1 (2.3 %)

77.5
17 (13.5 %)
12/5
4 (23.5 %)
9 (52.9 %)
3 (17.6 %)

Ethylism
AHT
DM
HF
RF
COPD
CVA
ND
Dyslipidemia
CT hypo
Iso
Mixed
Bilateral
Left
Right

1 (9.1 %)
8 (72.7 %)
4 (36.4 %)
2 (18.2 %)
1 (9.1 %)
1 (9.1 %)
2 (18.2 %)
1 (9.1 %)
3 (27.3 %)
2 (18.2 %)
4 (36.4 %)
5 (45.5 %)
2 (18.2 %)
7 (63.6 %)
2 (18.2 %)

8 (18.6 %)
28 (65.1 %)
7 (16.3 %)
10 (23.3 %)
7 (16.3 %)
6 (14.0 %)
8 (18.6 %)
11 (25.6 %)
8 (18.6 %)
10 (24.4 %)
10 (24.4 %)
23 (56.1 %)
13 (30.2 %)
13 (30.2 %)
17 (39.5 %)

3 (17.6 %)
13 (76.5 %)
6 (35.3 %)
7 (41.2 %)
5 (29.4 %)
2 (11.8 %)
6 (35.3 %)
7 (41.2 %)
5 (29.4 %)
2 (11.8 %)
3 (17.6 %)
12 (70.6 %)
2 (11.8 %)
7 (41.2 %)
8 (47.1 %)

984

Acta Neurochir (2014) 156:981987

Fig. 3 Symptoms and signs at

presentation

(13 %) and homogeneously isodense in 23 patients (18 %).

The differences in characteristics of patients needing repeat
surgery, having complications or in whom there was a fatal
outcome are listed in Table 1.

Outcome
Overall 106 out of 126 patients (84 %) showed clinical improvement at discharge, as shown by a decrease in the
Markwalder score postoperatively; 2 % had a Markwalder
score that did not alter after therapy. Fourteen percent had a
worse outcome, which meant a deadly outcome in all but one
patient. At discharge, 72 patients (57 %) were asymptomatic
(Markwalder 0), and 29 (23 %) had minimal residual symptoms (Markwalder 1). Five patients (4 %) had a neurological
deficit (Markwalder 2), and three patients (2 %) had several
focal signs (Markwalder 3) (Table 2). Mean hospital stay was
15,412.5 days.
Recurrence of the subdural hematoma requiring surgery
occurred in 11 patients (8.7 %).
Univariate analysis could not reveal a significant correlation between recurrence and one of the comorbidity factors,
risk factors or CT characteristics of the subdural hematoma.

Postoperative complications occurred in 43 patients

(34,1 %). They consisted of 27.8 % (35/43) of the medical
complications; 6.3 % (8/43) were surgical complications. In
the 35 patients who did a medical complication, 69 % suffered
pulmonary infections and 25 % urinary tract infections; the
other 6 % had a decubitus ulcer or deep venous thrombosis.
The surgical complications included two wound infections,
four epileptic seizures, an intracerebral hemorrhage and a
tension pneumocephalus (Table 3).
The only significant correlation was found with the presence of a neurodegenerative disease (p=0,018).
A logistic regression analysis of the different Markwalder
grades showed that a higher preoperative Markwalder grade
correlated with a higher risk of complications (Table 4).
Mean follow-up after discharge was 123.5 weeks (median
follow-up 73 weeks; range 2.6-440 weeks). Two (1.8 %) out
of 109 surviving patients were lost to follow-up, meaning they
were not seen at the outpatient clinic after discharge.
Overall 17 patients died (13.5 %) during their hospital stay:
11 patients because of a pulmonary infection (8.7 %). Two
deaths were directly related to the surgical management: one
developed an intracerebral hemorrhage, and another patient
developed a tension pneumocephalus. Four others were already comatose and did not wake up after surgery.

Table 2 Markwalder score preoperatively and at discharge

Preoperative
Markwalder

Markwalder at
discharge

Grade 0
Grade 1
Grade 2

0
31
74

0
26
62

72
29
5

57
23
4

Grade 3
Grade 4
Death
Better
Constant
Worse (including death)

14
7

6
5

3
0
17
106
2
18

2
0
13
84
2
14

Table 3 Medical and surgical related complications of mini-craniotomy

Medical

N (%)

Mortality (%)

Pulmonary infection
Urinary tract infection
Decubitus wound
Deep venous thrombosis
Surgical
Wound infection
Seizures
Pneumocephalus
Intracerebral hemorraghe
Total

24 (19.0)
9 (7.1)
1 (0.8)
1 (0.8)
N
2 (1.6)
4 (3.2)
1 (0.8)
1 (0.8)
43 (34.1)

11 (8.7)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
1 (0.8)
1 (0.8)
13 (10.3 %)

Acta Neurochir (2014) 156:981987

985

Table 4 Logistic regression table of Markwalder grade preoperatively

and complications postoperatively
Markwalder

Odds ratio p-value Lower 95 % CI Upper 95 % CI

Grade 2 versus 1.879

grade 1
Grade 3 versus 5.556
grade 1
Grade 4 versus 25.00
grade 1

0.225

0.679

5.200

0.015

1.393

22.162

0.006

2.514

248.575

The presence of arterial hypertension (p=0,038), heart

failure (p=0,02), renal failure (p=0,017), neurodegenerative
disease (p=0,001), cerebrovascular accident (p=0,008) and
coagulopathy (p=0,019) seemed significantly related to mortality in univariate analysis. However, multivariate analysis
could not confirm a significant correlation between these
comorbidities and mortality. Recurrence was not associated
with a higher mortality.

Discussion
After the landmark paper by Svien and Gelety in 1964 that
concluded that BHC is as effective as craniotomy but with
lower mortality and morbidity, the craniotomy technique was
largely abandoned, and BHC became the first surgical treatment of choice [27]. It should be noted however that in their
trial only 19 patients were treated by a large craniotomy with
total membranectomy, which is a significantly different technique from mini-craniotomy with membranotomy. This group
was then compared to a group of 50 patients treated with
BHC, indicating that selection bias plays a significant role in
this retrospective analysis.
Because of the more widespread use of CT and MRI
nowadays, CSDH is more frequently diagnosed, and the diagnosis is more often made at an early stage. The present
patient population is probably in a better general condition
than those included in the study of Svien and Gelety. In
addition, better neuro-anesthesia and progress in intensive
care have vastly decreased both operative and postoperative
risks for the neurologically critically ill patient [9]. Therefore,
we believe the conclusions of that paper, published in 1964,
cannot be translated to the current management of CSDH.
Recent meta-analyses have attempted to rationalize the
optimal treatment, but good quality data from well-designed
studies are still missing [7, 14, 30]. Lega et al. constructed a
decision analysis model, trying to overcome the paucity of
quality data and heterogeneity of the published results [14].
They concluded that BH was the most efficient choice for
surgical drainage of uncomplicated CSDH. They did mention
however that craniotomy has fewer recurrences but results in
significantly more frequent and serious complications. It bears

noting that the studies used to evaluate the craniotomy technique rarely make a distinction between mini-craniotomy,
large craniotomy, craniectomy or even burr hole treatment,
making a correct evaluation of the mini-craniotomy technique
impossible [7, 14, 30]. In addition, craniotomy is mostly
reserved for recurrent CSDHs or if membranes or large acute
blood are visualized on preoperative imaging, leading to an
important selection bias. Weigel et al. confirmed that the
studies used to evaluate the craniotomy technique may lead
to a distorted picture of the recurrence, mortality and morbidity [30]. To our knowledge, this is the first study where minicraniotomy was performed in a consecutive series of all types
of CSDH.
In the present study, the mean age of the patients suffering
from CSDH was 73.414.2 years. There was a male predominance of 67.5 %. A therapy with anticoagulants or antiplatelet
agents was present in 44 % (n=56), chronic alcohol abuse in
14 % (n=18) and a coagulopathy in 5.5 % (n=7). In 75
patients (59 %) a history of trauma could be elicited; 4 patients
had a ventriculo-peritoneal shunt as the leading cause. These
data are consistent with results from previously published
studies [23].
Recurrence is a common problem in the treatment of
CSDH. Earlier publications mention recurrence rates ranging
from 0.35 % to 60 %. In their evidence-based review of 48
publications describing treatment of CSDH, Weigel et al.
calculated a composite recurrence rate of 14.6 % for all
treatment modalities combined.
We have a significantly lower recurrence rate of only
8.7 %. In our view, this is a result of the better visualization
of the subdural space and the consequential possibility to open
more septae and constricting membranes and to cauterize
bleeding vessels.
Intuitively one might think that anticoagulant or antiplatelet
therapy might increase the recurrence rate, but studies investigating this topic have not been able to confirm this [3, 15]. In
our series, we could not establish any relationship between the
use of these anti-clotting agents and recurrence either.
Predictive factors for recurrence have been extensively
reviewed, encompassing pre-, peri and postoperative features [25]. A recent prospective study assessed the relationship
of CT scan features and recurrence of CSDH. They found that
preoperative hematoma volume and certain types (isodense,
hyperdense, laminar and separated) had a higher risk of recurrence [25]. Perioperative findings show that the presence of a
thick membrane visualized during surgery is also predictive
[20]. These findings are not surprising since they reflect the
stage of maturation of the hematoma and the risk of rebleeding
[19]. Since a craniotomy offers better results in CSDH with a
higher risk for recurrence, it has been suggested to perform a
preoperative MRI in order to better visualize the
intrahematomal structure and adapt the neurosurgical technique for every type of hematoma [28]. We did not find a

986

significant relation between CT characteristics and recurrence,

but since only 11 patients needed reoperation, these results
should be interpreted with caution.
Our low recurrence rate could on the other hand
indicate that mini-craniotomy is a suitable technique
for all types of CSDH.
The possibility exists that some patients presented with a
recurrence at a different hospital, but with only two patients
lost to follow-up and two patients with a follow-up period less
than 30 days, this would not change the outcome significantly.
We also have a substantially longer follow-up period than
most other studies.
Many publications have focused on the efficacy of drainage of minimally invasive procedures, but rarely discuss
complications. Rohde et al. did focus on the complication
rates. In their retrospective study, they analyzed 376
patients operated on with BHC, describing surgical
complications in 77 patients (20.5 %) and medical complications in 59 patients (15.7 %), giving a total complication rate of 136 patients (36.1 %) [21]. The overall
rate is in line with our complication rate (34.1 %);
however, we mainly have medical complications
(27.8 %) and few surgical complications (6.3 %). It
bears noting that of all medical complications, 15.2 %
were easily treated urinary tract infections. (Table 3).
Although rarely discussed, complications are of great clinical relevance as they are the leading cause of mortality. In our
series, 11 out of 17 patients (65 %) died because of a pulmonary infection, and 2 patients died from their surgical complications. One might assume that a less invasive technique
without the need for general anesthesia could lower the complication rate. This idea has been challenged by a study
comparing the bedside twist drill with a combined
group of BHC and craniotomy; complication rates were
shown to be similar between the two groups (36.3 in
the TDC group versus 33.3 in the combined BHC and
craniotomy group) [10].
As CSDH might be a marker of underlying chronic disease, a sentinel event exposing decreased function of important organ systems, it is not excluded that some of these medical
complications were already present before surgery [17].
The presence of dyslipidemia did seem to have a protective
effect with regards to complications; further investigation
showed that these patients took statins. This finding should
be interpreted with caution since only 37 patients had dyslipidemia, but a pleiotropic effect is not excluded. Patients under
anticoagulant or antiplatelet treatment did not suffer a higher
rate of complications. This finding is consistent with the
literature [4].
Our data show that the preoperative neurologic status is an
important prognostic risk factor for the development of complications. This is probably due to the longer hospitalization
stay of the critically ill patient.

Acta Neurochir (2014) 156:981987

An overall mortality rate of 13.5 % was found. Univariate

analysis of the comorbidity factors and mortality showed
different significant relationships [arterial hypertension
(p=0.038), heart failure (p=0.02), renal failure (p=0.017],
neurodegenerative disease (p=0.001), cerebrovascular accident (p=0.008) and coagulopathy (p=0.019). Nonetheless,
multivariate analysis was not able to confirm any significant
relation, presumably because of the fact that these older patients have multiple comorbidity factors that are related to
each other. Another explanation may be the relatively low
number of patients in each category.
In a study by Ramachandran et al., age, GCS at presentation and associated illnesses such as cardiac and renal failure
were significantly related to mortality. Our own results do
indeed confirm a significant relationship between mortality
and heart failure (p=0.02) and renal failure (p=0.017). Surprisingly, we did not see a linear relation between the
Markwalder grade and mortality.
Despite the mortality rate of 13.5 %, 84 % of the patients
were successfully treated and discharged home with 57 %
having no symptoms (Markwalder 0) and 23 % having only
mild neurological symptoms (Markwalder 1).
As results of recent literature show a significant variation in
reported mortality rates (3 %24 %), it is difficult to say
whether this mortality rate is high or low [5, 6, 18, 26].
Mini-craniotomy has already been proposed as an effective
compromise between the minimally invasive burr hole and
aggressive large craniotomy [1]. In our study, no relationship could be found between hematoma characteristics
on CT and higher recurrence, morbidity or mortality in
this study, suggesting that mini-craniotomy is indeed a
suitable technique for any type of CSDH, whether
isodense, hyperdense, hypodense or mixed with membranes. For the above-mentioned reasons, it is already
suggested as the primary technique for the treatment of
CSDH in children [13].
The present study is retrospective in nature, making it
potentially subject to sources of bias. As mini-craniotomy
was exclusively used to treat all types of CSDH in all
consecutive patients, selection bias was avoided. Another strength is the comparatively large sample size of
126 evaluable patients. The limitations of a retrospective
series still stand, however, and in order to determine
whether one technique is superior to the other, a well
set up prospective randomized controlled trial comparing mini-craniotomy with burr hole treatment and twist
drill craniostomy should be performed.

Conclusion
This is the first published series of CSDH in which all consecutive patients were operated on by mini-craniotomy.

Acta Neurochir (2014) 156:981987

Our retrospective analysis indicates that minicraniotomy is an effective surgical technique for all
types of CSDH, with results that compare favorably to
other, more frequently used intervention types. It should
therefore not be neglected as a primary surgical technique in the treatment of CSDH.
An RCT comparing different techniques for every type of
CSDH is indicated in order to identify the best surgical strategy in the treatment of CSDH.
Competing interests The authors have declared that no competing
interests exist.

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