Role of dural fenestrations in acute subdural hematoma

Object. Patients with acute subdural hematomas (ASDHs) have higher mortalit y and lower functional recovery rates compared with those of other head-inj ured patients. Early surgical decompression and active intensive care treat ment represent, so far, the best way to assist these patients. Paradoxicall y, one of the factors contributing to poor outcomes in cases of ASDHs could be rapid surgical decompression, owing to the severe extrusion of the brai n through the craniotomy defect in response to acute brain swelling. To avo id the deleterious consequences of abrupt decompression of the subdural spa ce with disruption of brain tissue, the authors have adopted a new surgical technique for evacuation of ASDHs. This procedure consists of creating mul tiple fenestrations of the dura (MFD) in a meshlike fashion and removing cl ots through the small dural openings that are left open, avoiding the creat ion of a wide dural opening and the disruption of and additional damage to brain tissue. Methods. Thirty-one patients (26 male and five female patients with a mean age of 32.5 years) harboring ASDHs were treated using this method. On admis sion there were 16 patients (51.5%) with Glasgow Coma Scale (GCS) scores of 3 to 5, 11 patients (35.5%) with GCS scores of 6 to 8, and four patients ( 12.9%) with GCS scores of 9 to 12. Postoperative computerized tomography sc ans of the brain revealed evacuation of more than 80% of the hematoma in 29 of 31 patients. The overall mortality rate in this group was 51.6%. Conclusions. This preliminary report of a new surgical approach for patient s who have sustained ASDHs should be considered to avoid abrupt disruption of the brain and to allow the gradual and gentle release of subdural clots. This is especially important in cases in which there are severe midline sh ifts and a tight brain. Further clinical studies should be conducted in a m ore selected series to estimate the impact of this new procedure on morbidi ty and mortality rates.