There were 30 cases, 25 males and 5 females, aged 70 years and above, mean 76.5 years (SD, 4.3) for this analysis. Of these 30 patients, 16 cases (53.3%) were 75 years and above; while 8 cases (26.7%) were 80 years and above.
Table 1 shows some of the radiological and clinical characteristics of the study subjects. The non-acute subdural haematoma was bilaterial in 30%(9/30); the rest were unilateral, either right or left, with the left having greater frequency, Fig. 3. Computed tomography (CT) scanning was the main radiologic diagnostic investigation in our patients; only a few got magnetic resonance imaging (MRI) and these were usually those for whom other neurological diagnoses (including brain tumour or stroke) were suspected by the primary-care physicians/neurologists before referral for neurosurgery. Radiologically the haematoma on CT was of mixed density in 73% (22/30), the rest hypo- or isodense. Figure 4 shows one of the cases of bilateral CSDH operated with this surgical technique
Clinical and radiological characteristics of the geriatric patients treated with this surgical technique
Laterality of subdural haematoma
Type of subdural by CT density
Loss of consciousness
Preceding history of trauma was obtained in 18/30 (60%). Most presented with gait impairment, cognitive decline, and headache, Table 1; and as shown in Table 2, as many as 17/30 (56.7%) presented in stupor or coma as assessed with the Markwalder grading scale.9–11 Some 40% (12/30) had background history of hypertension and 3 were on low-dose (75 mg) aspirin treatment; 10 (33.3%) had their initial clinical diagnosis as cerebrovascular accident. History of alcohol ingestion was obtained in only 2/30; none had coagulation disorder.
The clinical status of the patients, using the Markwalder grading scale, preoperatively and at in-hospital discharge
0, no symptoms
1, mild symptoms
2, focal deficit
The surgery was successfully completed in all, median duration 45.0 minutes (IQR 37.3–60.0). It was solely under local anaesthesia in 77% (23/30); momentary sedation with bolus doses of Propofol, a short-acting agent, was added in the rest for occasional intraoperative restlessness. There was not any episode of intraoperative adverse events. The postoperative recovery was brisk in most patients and the median in-hospital stay before discharge was 7 days (IQR 5–11).
Outcome was very good in 83.3% (25/30) using the modified Rankin Scale (mRS) including two-third (20/30) completely asymptomatic (mRS 0), and 5/30 with only slight symptoms and no disability, (mRS 1). Of the other 5 patients; 2 were mRS 2, with slight disability at discharge. Three patients died, all from those that presented in coma, Table 2. Postoperative CT scanning was acquired in only 8 usually for some concerning postoperative clinical issues. All the patients that were discharged home were followed up in the outpatient department, median duration of 3.5mo (IQR 2–12); some 70% of the total patient cohort (21/30) have been followed up for more than 3 months.
There were 3 cases of subdural haematoma recurrence, all ipsilateral and in unilateral cases, in our study subjects.
One was actually a failure of the surgery, technically. It involved an 87-year-old man who presented in coma, and was operated for a left-sided mixed-density CSDH with this technique. He made brisk recovery postoperatively; wound staples were removed on POD 6, and was being reviewed for possible in-hospital discharge after which his neurological status progressively declined again. Repeat brain CT on POD 13 revealed a persistent parietal hypodense collection, Fig. 5. In retrospect, this was merely the parietal loculation of the initial layered fronto-parietal collection which apparently was ensconced from the frontal subdural component by another capsule, Fig. 5a. At repeat surgery through the same left frontal burr-hole, the outer capsule of this ensconced parietal CSDH was merely sought, and fenestrated generously; the content was emptied, and the cavity irrigated till clear as usual. He thereafter made brisk recovery and was discharged home in excellent clinical state (Markwalder 0, mRS 0), on POD 5. He remains well some 6 years after that surgery. This was early in this surgical experience. We have since learnt to always seek out the inner outer membranes of compartmentalized CSDHs, fenestrate them, and then irrigate them till clear in the subsequent years.
The next recurrence involved an 82-year-old woman who made good recovery, mRS grade 0, from the first surgery (Fig. 6a, b), but 2 months later showed clinical and radiological recurrence, Fig. 6c). She was re-operated through the same frontal burr-hole; had good recovery, Fig. 6d, and in-hospital outcome, again, mRS 0; and was followed-up for 8 months in clinic before discharge.
The last case of recurrence in this series involved a 76-year-old man who recovered briskly from the first surgery, and was discharged home mRS 0, on POD 4; was seen as outpatient on POD 10 for stitch removal, but then represented on POD 16 with clinical and radiological recurrence. He was re-operated with good recovery, mRS 1, too.