Work

Higher risk, lower recurrence: A year of risk-adapted twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy for chronic subdural hematoma

Year: 2026

Type: article

Abstract: Introduction: Recurrence remains challenging in chronic subdural hematoma (cSDH). Twist-drill craniostomy (TDC) permits bedside treatment, but incomplete evacuation limits its effectiveness in membranous hematomas. Thus, we introduced TDC with pressure-controlled fibrinolytic irrigation therapy (TDC-FIT). Research question: Within an institutional risk-adapted treatment algorithm, how does the reoperation risk compare after TDC-FIT versus TDC? Material and methods: All patients undergoing cSDH surgery in 2025 were included. TDC-FIT was preferentially used for recurrent and/or membranous cSDH. The primary outcome was ipsilateral recurrent/persistent cSDH requiring surgery <3 months. Procedure-level analyses used robust patient-clustered standard errors, and patient-level sensitivity analyses. Results: 208 procedures were performed in 139 patients; 191 procedures in 130 patients were eligible for the primary analysis. Reoperation occurred after 2/39 TDC-FIT (5.1%) and 35/152 TDC procedures (23.0%; RR 0.22, 95% CI 0.05-0.93; P = 0.040), an absolute risk difference of -17.9 percentage points. The adjusted RR was 0.16 (95% CI 0.03-0.74; P = 0.020). Patient-level RRs were 0.25 for index surgery, 0.15 for first recurrent or persistent episode, and 0.17 for membranous configurations; estimates were imprecise. Procedure-related complications occurred after 6/43 TDC-FIT procedures and 12/165 TDC procedures (RR 1.92, 95% CI 0.75-4.91; P = 0.174). Conclusion and discussion: Within this risk-adapted algorithm, TDC-FIT was associated with fewer reoperations, despite preferential use in higher-risk cSDH. Patient-level estimates were directionally consistent but imprecise. Complications were numerically more frequent after TDC-FIT, and equivalent safety cannot be inferred. Randomized studies are needed to establish effectiveness and safety.

Source: Brain and Spine

DOI: 10.1016/j.bas.2026.107487