Bedside Treatment of Chronic Subdural Hematoma: Using Radiographic Characteristics to Revisit the Twist Drill

Background and Study Aims Conventional treatment strategies for the management of symptomatic chronic subdural hematoma (cSDH) in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits. The goal of this study was to identify radiographic characteristics on computed tomography scan that might be used to guide surgical decision making in terms of operative versus bedside removal of cSDH. Methods We retrospectively reviewed clinical and radiographic features in patients who underwent bedside twist drill evacuation of a cSDH and those for a cohort of patients who underwent operative intervention via burr holes. Results We did not identify any clinical features or preoperative imaging characteristics to suggest an advantage of one procedure over the other. Additionally, complete radiographic resolution of cSDH on postoperative imaging is not required to relieve patient symptoms. Conclusion Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier resumption of anticoagulation treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates.