It was with great interest that we read the article by Latini et al.1 which was recently published in Neurología under the title “Minimally invasive treatment of chronic subdural haematoma in the adult: results in 116 patients”. Based on our experience treating these haematomas in daily practice, we would like to make a few comments.2
First of all, we were surprised by the inclusion criteria used to define chronic subdural haematoma (CSDH) as seen using computed tomography (CT). The authors described CSDH as “convex, hypodense, crescent-shaped images adjacent to brain parenchyma”. Although this image is typical of CSDH, we must not lose sight of the fact that it may present other morphologies and densities depending on its progression timeline.3 According to our experience, 22.3% of CSDH cases were not hypodense and appeared as isodense, hyperdense, or mixed-density haematomas.4
Secondly, we do not clearly understand which technique was used. We suppose that when the authors refer to trans-marrow puncture, they mean the twist-drill technique, that is, craniostomy performed with a fine drill bit (4–6mm), which is fully documented in the literature.5,6 What is the purpose of measuring intracranial pressure in these patients?
Thirdly, the authors examined 127 patients and only used their trans-marrow puncture technique in 116 patients. It therefore does not make sense to provide that number and then mention a patient total of 127 in the results/discussion sections, which list 11 patients treated with other techniques. The mortality of the technique cannot be given as 6 cases (4.7%), since this figure also includes one or more patients treated with other techniques.
The authors state that the failure rate of the technique is 17%, but this figure is incorrect. They indicate that trans-marrow puncture was the initial treatment for 116 patients, and that the haematoma only resolved after the first attempt in 57 patients (49%). If 39 patients required a second TMP procedure, and another 20 required additional different procedures, the failure rate of the technique due to haematoma recurrence, as described in the literature, would therefore be 51%. We feel that this figure raises doubts about the technique.
Lastly, we agree with the authors that a large-scale prospective randomised study is needed in order to determine the best treatment for CSDH. While such a study is still lacking, the overwhelming consensus of the literature is that ideal treatment for CSDH consists of one or two burr holes (employing local anaesthesia, whenever possible) and implantation of a subdural drain; this step may or may not be preceded by saline irrigation of the subdural space.7,8
Please cite this article as: Gelabert González M, et al. Tratamiento mínimamente invasivo del hematoma subdural crónico del adulto. Resultados en 116 pacientes. Neurología. 2012;27:311–2.
