Twist-Drill Craniostomy With Pressure-Controlled Fibrinolytic Irrigation Therapy for the Evacuation of Acute Traumatic Subdural Hematoma in Patients Not Requiring Immediate Craniotomy.

BACKGROUND AND OBJECTIVES: Acute subdural hematoma (aSDH) ranks among the most prevalent conditions in neurosurgery. Depending on the hematoma and neurological condition, management is surgical or conservative. Open craniotomy is the mainstay of therapy if evacuation is mandated but is associated with considerable risks. We present a novel minimally invasive approach-twist-drill craniostomy with pressure-controlled subdural fibrinolytic irrigation (TDC-FIT)-for safe and efficient removal of aSDH in patients not requiring immediate evacuation and evaluate the outcome. METHODS: From June to December 2023, 10 patients with aSDH, Glasgow Coma Scale ≥13, hematoma thickness ≥7 mm, moderate neurological deficits without symptom progression, and no need for immediate evacuation were treated with TDC-FIT. A catheter with pressure-controlled irrigation containing an electrolyte solution with 200 000 IU/L urokinase at a target rate of 100 mL/h was inserted into the aSDH through a 3.5 mm TDC under local anesthesia. Irrigation was performed until radiological clearance of the aSDH was obtained. Outcome was compared with 30 historical matched controls treated with open craniotomy (Craniotomy cohort). RESULTS: In the TDC-FIT cohort, a near-complete hematoma resolution was observed in 9 (90%) patients, with 1 later recurrence of a chronic SDH, which subsequently resolved without additional sequelae after a conventional TDC. A total of 9 (90%) patients achieved independence (modified Rankin Scale 0-3) at 3 months, compared with 17 (56.7%) in the Craniotomy cohort (P = .012). One (10%) patient necessitated an open craniotomy because of neurological deterioration. The Craniotomy cohort experienced perioperative complications in 17 (56.7%) cases. Aphasia occurred in 2 (6.7%), hemiparesis in 4 (13.3%), epilepsy in 8 (26.6%), rehemorrhage in 2 (6.7%), meningitis in 1 (3.3%), and death in 2 (6.7%) patients. CONCLUSION: TDC-FIT on aSDH may offer a safe and effective alternative to open surgery in patients not requiring immediate evacuation.