A 45-year-old man presents with a chronic subdural haematoma (CSDH) causing midline shift of 10 mm and progressive hemiplegia. He is on aspirin. What is the definitive surgical treatment?
- A Burr hole drainage of the haematoma under local or general anaesthesia ✓
- B Craniotomy and clot evacuation under general anaesthesia
- C Conservative management with corticosteroids and repeat imaging in 6 weeks
- D Twist drill craniostomy with drain insertion
Explanation
Symptomatic chronic subdural haematoma with significant midline shift and neurological deficit is treated with burr hole drainage, which is the preferred technique (vs craniotomy) due to its lower morbidity, equivalent or superior efficacy for CSDH (which is liquefied and does not require formal craniotomy), and suitability under local anaesthesia in elderly/comorbid patients. Aspirin should be stopped pre-operatively. Craniotomy is reserved for recurrent CSDH, organized clot, or cases with failure of burr hole drainage. Conservative management with steroids (dexamethasone) has emerging evidence but is not first-line for symptomatic midline shift.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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