Higher risk, lower recurrence: A year of risk-adapted twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy for chronic subdural hematoma.
- 1Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
- 2Department of Neurosurgery, Ruhr-University Bochum, Universitaetsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Germany.
- 3Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
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.
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BibTeX
@article{doriamedina2026higher,
title = {{Higher risk, lower recurrence: A year of risk-adapted twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy for chronic subdural hematoma.}},
author = {Roberto Doria-Medina and Marco Bissolo and István Csók and Lucas Becker and Manou Overstijns and Mazin Omer and Mukesch Johannes Shah and Jürgen Beck and Roland Roelz},
journal = {Brain \& spine},
year = {2026},
month = oct,
doi = {10.1016/j.bas.2026.107487},
url = {https://europepmc.org/article/MED/42960131},
note = {CC BY},
}
RIS
TY - JOUR
TI - Higher risk, lower recurrence: A year of risk-adapted twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy for chronic subdural hematoma.
AU - Roberto Doria-Medina
AU - Marco Bissolo
AU - István Csók
AU - Lucas Becker
AU - Manou Overstijns
AU - Mazin Omer
AU - Mukesch Johannes Shah
AU - Jürgen Beck
AU - Roland Roelz
PY - 2026
DA - 2026/10/21
JO - Brain & spine
DO - 10.1016/j.bas.2026.107487
UR - https://europepmc.org/article/MED/42960131
AB - 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.
SN - 2772-5294
ER -