CLINICAL ARTICLE

J Neurosurg 131:1227–1234, 2019

Contralateral progression after unilateral evacuation

of bilateral chronic subdural hematomas: the volume
relation ratio as prognostic factor?
Florian Scheichel, MD,1,2 Branko Popadic, MD,1,2 Karl Ungersboeck, MD,1,2 and Franz Marhold, MD1,2
1
Department of Neurosurgery, University Hospital of St. Poelten; and 2Karl Landsteiner University of Health Sciences, Krems an
der Donau, Lower Austria, Austria

OBJECTIVE Unilateral evacuation of bilateral chronic subdural hematomas (bcSDHs) is associated with higher retreat-
ment rates than an initial bilateral intervention. One reason for that is a possible progression in the size of the contralat-
eral side after unilateral treatment. Thus, the authors focused their study on finding predictors of the need for contralat-
eral retreatment.
METHODS All patients who had undergone unilateral or bilateral evacuation of bcSDHs in the Department of Neuro-
surgery at the University Hospital of St. Poelten during a 5-year period (7/2012 to 6/2017) were retrospectively identified.
The preoperative hematoma volume was calculated using the XYZ/2 method.
RESULTS Of a total of 103 patients with bcSDHs, 61 patients underwent bilateral evacuation and 42 patients underwent
unilateral evacuation. The retreatment rate after bilateral evacuation was significantly lower than that after unilateral
evacuation (14.8% vs 31%, respectively; p = 0.049). Contralateral retreatment after unilateral evacuation was necessary
in 9 patients (21.4%). The preoperative contralateral hematoma volume was significantly higher in those patients who
needed contralateral retreatment after initial unilateral evacuation (68.4 cm3 vs 27.4 cm3, respectively; p < 0.001). Fur-
thermore, the so-called volume relation ratio created by dividing the smaller by the larger hematoma volume was signifi-
cantly higher when contralateral retreatment became necessary (0.56 vs 0.21, respectively; p < 0.001).
CONCLUSIONS Patients needing evacuation of bcSDHs should be considered for primary bilateral evacuation if the
hematoma volume on the smaller side is greater than 40 cm3 and the subsequent volume relation ratio is greater than 0.4.
https://thejns.org/doi/abs/10.3171/2018.6.JNS18467
KEYWORDS chronic subdural hematoma; bilateral; retreatment; trauma

C
hronic subdural hematoma (cSDH) is a common and bcSDH, indication for surgery is generally accepted
diagnosis in neurosurgery. The incidence is up to in symptomatic patients. Various surgical techniques have
13.1 per 100,000/year with an increase in the el- been used for years. Burr hole craniostomy with or without
derly.4,5,8 A cSDH is a slowly progressive collection of insertion of a closed drainage system is the most frequent
liquefied SDH arising in 50% to 80% after minor head performed procedure.9,20
trauma.4,14,18 The time interval from trauma to onset of However, recurrence of cSDH requiring ipsilateral re-
symptoms is often delayed. Known additional risk factors operation is common. The reported rate ranges from 9.2%
are antiplatelet or anticoagulant therapy, age, and brain at- to 26.5%.1,2,10–12,15 Moreover, in bcSDHs the retreatment
rophy.4,14 rate reaches almost 30%.7,13,19 Noted retreatment rates for
Bilateral cSDHs (bcSDHs) account for 17.4%–34.9% of bcSDHs in the literature depict both surgery for ipsilat-
cSDH cases.7,17,19,21 eral recurrence and surgery for contralateral progression
Although there is no standardized treatment for cSDH after initial unilateral hematoma evacuation. Because of

ABBREVIATIONS bcSDH = bilateral chronic subdural hematoma; CCT = cranial CT; cSDH = chronic subdural hematoma; ICP = intracranial pressure; VR-ratio = volume
relation ratio.
SUBMITTED February 18, 2018. ACCEPTED June 12, 2018.
INCLUDE WHEN CITING Published online November 23, 2018; DOI: 10.3171/2018.6.JNS18467.

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Scheichel et al.

their different underlying pathomechanisms, ipsilateral The depth was multiplied by the maximum length on any
recurrence and contralateral progression should be distin- slice and the maximum width on any slice and then di-
guished. vided by 2.
Recently, unilateral evacuation of bcSDHs has been
identified as an independent risk factor for retreatment.3 Volume Relation Ratio
For all patients requiring retreatment after unilateral To determine if there was interaction between the indi-
evacuation of a bcSDH, more than 50% need contralateral vidual volume and mass effect of both hematomas, we de-
hematoma evacuation.3 Thus, it seems crucial to identify fined a variable called the volume relation ratio (VR-ratio).
those patients who could profit from initial bilateral evac- The VR-ratio was calculated by dividing the volume of
uation. the smaller contralateral hematoma by the volume of the
To the best of our knowledge, there are no distinct pa- larger ipsilateral one. To the best of our knowledge, this
rameters predicting a contralateral progression after uni- was done for the first time in cSDHs.
lateral evacuation of bcSDHs. The decision whether to
evacuate one or both sides initially is mainly based on the
size of each hematoma, mass effect demonstrated on im- Patient Characteristics and Surgical Treatment
aging studies, and lateralization of symptoms. There are Demographic and clinical data including sex, age,
no standardized parameters that could be used repeatedly symptoms, anticoagulant or antiplatelet therapy, history of
in different patients. head trauma, and outcome were culled from medical re-
Therefore, we focused in this analysis on finding pre- cords. Surgical data included side of evacuation, surgical
dictors for contralateral retreatment in bcSDHs after uni- procedure, and usage of a closed drainage system. Indica-
lateral evacuation. tion for surgery and the decision of whether to perform
burr hole craniostomies or craniotomies with or without
insertion of a drainage system were made by the attending
Methods neurosurgeon.
We performed a retrospective single-center analysis of The standard surgical procedure for cSDH at our in-
all surgically treated patients with bcSDHs from July 1, stitution consists of single– or double–burr hole cranios-
2012, to June 30, 2017, at the University Hospital of St. tomy and insertion of a closed drainage system. In cases
Poelten, Austria (Karl Landsteiner Private University of involving rather small hematoma volumes and intraop-
Health Sciences). This study was approved by the ethics erative reexpansion of brain parenchyma after hematoma
commission of Lower Austria, Austria. A database query evacuation, the attending surgeon could decide against a
searching for specific treatment codes (craniostomy, cra- drainage system when it could not be safely inserted. The
niotomy) was performed to identify those patients treated attending surgeon may have decided to perform a crani-
for cSDH, either cSDH or bcSDHs, during this 5-year pe- otomy in a case of distinct membranous cSDH.
riod consecutively. To identify all patients with bcSDHs,
the latest cranial CT (CCT) scan obtained prior to sur- Retreatment
gery was reviewed, and only patients with bcSDHs were
included in the study. Retreatment was defined as every subsequent surgery
The exclusion criteria were patient age younger than 20 necessary due to a progressive contralateral hematoma,
years, a history of ventricular shunt implantation, and de- recurrence of the evacuated ipsilateral hematoma, or in-
compressive craniectomy or any other previous cranioto- complete evacuation of the ipsilateral hematoma with re-
my due to a possibility of a difference in pathophysiology. maining mass effect. Information regarding retreatment
In patients harboring a possible acute SDH, all the data included side of retreatment (ipsi- or contralateral), time
were meticulously reviewed. In cases of a cSDH, which to retreatment, and preoperative hematoma volume on the
appeared dubious, the patients were excluded. latest CT scan before the second surgery for contralateral
The mean radiological follow-up duration was 172.8 retreatment. Follow-up CT scans and outpatient reports
days. were analyzed to find patients with recurrence.
Patients who had undergone unilateral hematoma
Preoperative Imaging evacuation of bcSDHs were then divided into two groups:
All patients underwent CCT before surgery. We ana- group A included patients with contralateral retreatment
lyzed the cSDH in terms of acuity, size, volume, location and group B included patients without contralateral re-
density, and midline shift on the last CCT scan before sur- treatment. Attributes were compared between the groups
gery. to find predictors for contralateral retreatment after unilat-
The hematoma density of each side was classified as eral evacuation.
homogeneous, separated, laminar, or membranous based
on the description of Nakaguchi et al.10 The preopera- Statistical Analysis
tive hematoma volumes were calculated on the last CT For statistical analysis, we used SPSS statistical soft-
scan acquired before surgery using the XYZ/2 method, ware (IBM Corp.). For qualitative variables, a chi-square
which has been described to be valid for cSDH by Sucu test was performed; for continuous variables, a Student t-
et al.16 To calculate the hematoma volume, we identified test was executed. A p value < 0.05 was considered statis-
the depth by multiplying the number of axial slices on tically significant. Cutoff values were found with receiver
which the hematoma was visible with the slice thickness. operating characteristic curve analysis.

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TABLE 1. Clinical, demographic, and surgical data TABLE 2. Comparison of groups A and B
No. of Cases or % or No. of Patients (%) or
Variable Mean Value SD Mean Value
Patients 103 100 Contralat No Contralat
Retreatment Retreatment p
Sex
Variable (%) (%) Value
Male 69 67.0
Female 34 33.0 Patients 9 (21.4%) 33 (78.6%)
Mean age in yrs 76.8 ±9.4 Sex NS
Clinical presentation Male 6 (66.7%) 20 (60.6%)
Headache 35 34.0 Female 3 (33.3%) 13 (39.4%)
Nausea & vomiting 7 6.8 Density of the contralat hema- NS
toma on preop CT scan
Hemiparesis 33 32.0
  Homogeneous 5 (55.6%) 14 (42.4%)
Neuropsychological changes 66 64.1
  Laminar 0 (0%) 12 (36.4%)
Clouding of consciousness 22 21.4
  Separated 3 (33.3%) 3 (9.1%)
CT density, right side
  Membranous 1 (11.1%) 4 (12.1%)
Homogeneous 43 41.7
Midline shift, mm 7.6 ± 5.8 7.4 ± 3.6 NS
Laminar 15 14.6
Anticoagulant or antiplatelet NS
Separated 29 28.2
therapy
Membranous 16 15.5
  Yes 8 (88.9%) 20 (60.6%)
CT density, left side
  No 1 (11.1%) 13 (39.4%)
Homogeneous 38 36.9
Side of evacuation NS
Laminar 22 21.4
Right 3 (33.3%) 14 (42.4%)
Separated 23 22.3
Left 6 (66.7%) 19 (57.6%)
Membranous 20 19.4
Surgical procedure NS
Surgery location
1–burr hole craniostomy 6 (66.7%) 18 (54.5%)
Unilateral evacuation 42 40.8
2–burr hole craniostomy 0 (0%) 9 (27.3%)
  Right 17
Craniotomy 3 (33.3%) 6 (18.2%)
  Left 25
Drain used NS
Bilateral evacuation 61 59.2
Yes 8 (88.9%) 31 (93.9%)
Mean preop hematoma vol, cm3
No 1 (11.1%) 2 (6.1%)
Bilateral evacuation
Ipsilat hematoma vol, cm3 121.0 ± 31.4 140.6 ± 48.3 NS
   Right hematoma vol 120.8 ±47.1
Contralat hematoma vol, cm3 68.4 ± 24.2 27.4 ± 15.9 <0.001
   Left hematoma vol 123.3 ±49.7
VR-ratio (smaller vol/larger vol) 0.56 ± 0.11 0.21 ± 0.12 <0.001
Right evacuation
   Right hematoma vol 136.6 ±40.3 NS = not significant.
Hematoma volumes and the VR-ratio are expressed as mean ± SD.
   Left hematoma vol 33.7 ±23.4
Left evacuation
   Right hematoma vol 38.7 ±25.8
   Left hematoma vol 136.3 ±49.7 Results
Surgical procedure in bilateral op A total of 103 patients with bcSDHs were included in
1–burr hole craniostomy 39 63.9 this study. Of these 103 patients, 69 (67%) were male and
2–burr hole craniostomy 15 24.6 34 (33%) were female. Their age ranged from 21.7 to 92.9
Craniotomy 7 11.5 years (mean 76.8 years). Preoperative antiplatelet or anti-
Drain 58 95.1
coagulant therapy was administered in 59 patients (57.3%).
Head trauma was noted in 73 patients (70.9%).
No drain 3 4.9 Clinical, demographic, and surgical data are summa-
Surgical procedure in unilateral op rized in Table 1.
1–burr hole craniostomy 24 57.1
2–burr hole craniostomy 9 21.4 Hematoma Volumes
Craniotomy 9 21.4 The mean hematoma volume was 120.8 cm3 (± 47.1
Drain 39 92.9 cm3 [SD]) on the right side and 123.3 cm3 (± 49.7 cm3)
No drain 3 7.1 on the left when bilateral evacuation was performed. In
patients who underwent unilateral evacuation, the mean
hematoma volumes were 136.6 cm3 (± 40.3 cm3) on the

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FIG. 1. Left: Box plot illustrating the preoperative contralateral hematoma volume in patients with and without contralateral
retreatment after unilateral evacuation of bcSDHs. Right: Bar graph showing contralateral retreatment rates for patients with a
preoperative contralateral hematoma volume of less than 40 cm3, between 40 and 60 cm3, and greater than 60 cm3. ccm = cubic
centimeters (cm3).

right side and 33.7 cm3 (± 23.4 cm3) on the left side after Retreatment Rates
right-sided evacuation and 38.7 cm3 (± 25.8 cm3) on the The overall retreatment rate was 21.4% (22 cases). The
right and 136.3 cm3 (± 49.7 cm3) on the left after left-sided retreatment rate for patients who had undergone bilateral
evacuation. evacuation was 14.8% (9 cases), which was significantly
lower than that for patients who had undergone unilateral
Side of Evacuation and Procedure evacuation (31%, 13 cases) (p = 0.049). The majority of
Initial bilateral hematoma evacuation was performed in these 13 cases (9 cases, 69.2%) needed retreatment on
61 patients (59.2%), whereas initial unilateral evacuation the contralateral side, and the remaining 4 cases (30.8%)
was performed in 42 patients (40.8%). Of these unilateral needed ipsilateral retreatment.
evacuated bcSDHs, slightly more patients underwent left-
sided evacuation (59.5%, 25 cases) than right-sided evacu- Contralateral Retreatment After Unilateral Evacuation
ation (40.5%, 17 cases).
In patients who initially underwent bilateral hematoma The group that needed contralateral retreatment after
evacuation, craniotomy on at least one side was performed unilateral surgery (n = 9, group A) was compared with
in 11.5% (7 cases), a single burr hole was made in 63.9% the group that did not need contralateral retreatment (n =
(39 cases), and double burr holes were created in 24.6% 32, group B). The results are listed in Table 2. Differences
(15 cases). in sex, density shown on the preoperative CT scan, anti-
In patients who underwent unilateral evacuation, cra- coagulation and/or antiplatelet status, surgical procedure,
niotomies were performed in 21.4% (9 cases), a single midline shift, and hematoma volume of the hematoma on
burr hole was created in 57.1% (24 cases), and double burr the evacuated side did not reach statistical significance.
holes were made in 21.4% (9 cases). The mean preoperative hematoma volume on the un-
A drainage system was used in 94.2% of the patients (n treated, contralateral side was significantly larger in those
= 97). In terms of frequency of drainage insertion, there who needed contralateral retreatment (68.4 cm3 vs 27.4
was no significant difference between patients who under- cm3; p < 0.001).
went unilateral (92.9%, 39 cases) or bilateral (95.1%, 58 The ratio between the smaller, contralateral hema-
cases) evacuation. toma volume and the larger, ipsilateral evacuated hema-

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toma volume was significantly higher in group A than in

group B and is therefore called VR-ratio (0.56 vs 0.21;
p < 0.001).
A cutoff value for the VR-ratio of 0.4 produced a sen-
sitivity of 1 and a specificity of 0.91 for contralateral re-
treatment (area under the receiver operating characteristic
curve 0.976, 95% CI 0.938–1.000; p < 0.001).
The mean time to contralateral retreatment after uni-
lateral evacuation was 28 days (± 16.7 days). In one patient
the hematoma volume before contralateral retreatment
could not be assessed because the patient only had hard
copies of the preoperative CT scans that were not acces-
sible retrospectively. The mean hematoma volume of the
progressive contralateral side of the remaining 8 patients
was 148.6 cm3 (± 39.5 cm3) on the CT scan obtained be-
fore reoperation.

Discussion
Despite the fact that cSDH is such a frequent condition
in neurosurgery, there is no standard protocol for decid-
ing in which patients surgical evacuation should be per-
formed. The decision is mainly based on parameters such
as the size of the hematoma, its mass effect, and midline
shift on CT scans, as well as neurological symptoms and
the patient’s clinical condition.
In patients with bcSDHs, focal neurological deficits are FIG. 2. Upper: CT scans obtained in a 92-year-old man with bcSDHs.
Despite relatively high absolute hematoma volumes of 80.6 cm3 on the
less common, while symptoms due to high intracranial right side and 216.5 cm3 on the left side, the VR-ratio was only 0.37. The
pressure (ICP), such as vomiting and nausea, are more fre- patient underwent single–burr hole evacuation of the left-sided hema-
quent.7,17 Furthermore, midline shift is not as common and toma and placement of a closed drainage system. Lower: CT scans
distinct in cases of bcSDH.6,7,17 showing complete remission of the contralateral right-sided hematoma
In our study the mean hematoma volumes in patients in 14 months after the unilateral evacuation. This case illustrates the limi-
whom bilateral surgical evacuation was performed were tation of using only absolute hematoma volume numbers for decision
making to evacuate the contralateral hematoma.
120.8 cm3 (right) and 123.3 cm3 (left). Unilateral evacu-
ation was performed in patients with mean hematoma
volumes of 136.6 cm3 (right) and 136.3 cm3 (left) (Table in bcSDH is not based on any studies, and to date there
1). Even though there were relatively high standard devia- are no parameters that predict a contralateral progression
tions, this shows that the indication for surgical treatment after unilateral evacuation.
of bcSDHs was comparable across the groups. In our study there was a statistically significant differ-
A recent study concerning bcSDHs that included 264 ence in the mean contralateral preoperative hematoma
patients showed an overall retreatment rate of 21.6%. Ad- volume between groups A (contralateral retreatment) and
ditionally, unilateral evacuation of bcSDHs was identified B (no contralateral retreatment) (Fig. 1 left; Table 2). The
as an independent risk factor for surgical retreatment. The contralateral retreatment rate was only 3.6% if the con-
authors did not find any predictors of contralateral retreat- tralateral hematoma volume was under 40 cm3. While it
ment after unilateral evacuation.3 On the other hand, the seems obvious that a larger hematoma will more likely
increased risk of injuring the underlying brain tissue or need surgery in the future, our data indicate a cutoff at
missing a rather small cSDH has to be taken into account 40 cm3 and 60 cm3 (Fig. 1 right). With a contralateral he-
when considering initial bilateral evacuation. matoma volume between 40 cm3 and 60 cm3 or over 60
In our study, the retreatment rate after unilateral evacu- cm3, the retreatment rates increased to 28.6% and 85.7%,
ation of a bcSDH was 31.0% and was therefore signifi- respectively.
cantly higher than after bilateral evacuation (14.8%). One reason for the higher retreatment rate after uni-
The ipsilateral reoperation rate after unilateral evacua- lateral treatment could be a progression of the contralat-
tion of a bcSDH was only 9.5% (4 cases) and thus close to eral hematoma due to a reduction in ICP owing to uni-
the reoperation rate in unilateral cSDH shown in a recent lateral evacuation. One could expect that the larger the
meta-analysis (11.5%).2 The contralateral retreatment rate evacuated ipsilateral hematoma, the higher the pressure
after unilateral evacuation was 21.4% (9 cases). Contralat- relief on the contralateral side, and therefore the hema-
eral retreatment became necessary due to a progression in toma would be more likely to expand regardless of the
size of the untreated hematoma from a mean volume of size of the contralateral hematoma. However, there was
68.4 cm3 (± 24.2 cm3) before initial unilateral surgery to no significant difference in ipsilateral hematoma volume
148.6 cm3 (± 39.5 cm3) before retreatment. The decision of between group A and group B (121.0 cm3 vs 140.6 cm3;
whether to simultaneously evacuate the smaller hematoma Table 2). A possible explanation for this may be that the

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FIG. 3. CT scans obtained in two representative cases. A: CCT scan acquired in a 74-year-old man with bcSDHs. The hematoma
volumes on the left and right sides were 93.4 cm3 and 64.4 cm3, respectively (VR-ratio 0.69). Due to hemiparesis on the right side,
the patient was initially treated with unilateral left-sided hematoma evacuation through a craniotomy and a closed drainage system.
B: CCT scan showing bcSDHs in an 82-year-old man who barely exhibited any symptoms (hematoma volumes 149.6 cm3 [left] and
73.1 cm3 [right]; VR-ratio 0.49). The patient underwent left-sided single–burr hole craniostomy and placement of a closed drain-
age system. C and D: Scans obtained in the same patients as on A and B, respectively, showing progression of the contralateral
subdural hematoma 17 and 40 days after their initial surgery. The hematoma volumes have increased to 133.7 cm3 and 124.1 cm3,
respectively, making an additional evacuation necessary.

contralateral hematoma does not always have the ten- toma volume is different in every individual patient and
dency to progress or is, at the time of unilateral surgery, shows great variations. A small hematoma can produce
already regressing. The contralateral hematoma seems to a distinct mass effect and cause symptoms in a young
expand only when the elevated ICP is the main factor that patient, while, in the presence of brain atrophy, a rather
prevented it from doing so. Thus it seems to be a complex large hematoma can be compensated for easily. The VR-
relationship between both hematomas and the brain pa- ratio removes the individual factor from the equation and
renchyma that needs to be analyzed. In the presence of produces an objective parameter to show the influence of
mass effect through a bcSDH, brain atrophy cannot easily one hematoma on the other. In combination with the ab-
be assessed on imaging studies. Therefore, a ratio deter- solute hematoma volumes, the VR-ratio tries to describe
mined by dividing the volume of the smaller hematoma the interaction of all intracranial components.
by the volume of the larger hematoma was generated to In patients in whom contralateral retreatment became
describe the relation between both hematomas and was necessary, the VR-ratio was significantly higher (0.56 vs
named VR-ratio by the authors. The VR-ratio works as 0.21), with a cutoff value of 0.4 (a sensitivity of 1 and a
a possible surrogate parameter for the pressure relation specificity of 0.91).
between both hematomas. The higher the VR-ratio the Figure 2 shows CT scans obtained in a patient who un-
closer was the volume of the contralateral, smaller he- derwent unilateral surgery because of rapid clinical dete-
matoma to the larger one, which was large enough to rioration; the preoperative contralateral hematoma volume
indicate the need for surgical evacuation. Furthermore, was 80.6 cm3. Taking only the absolute numbers of the
this ratio draws the attention away from the absolute he- hematoma volumes into account, this patient should have
matoma volumes to the relation of each side’s hematoma initially undergone evacuation on both sides. The VR-ratio
volume. Absolute volume numbers are more dependent in this patient was 0.37. In the presence of distinct brain
on individual factors such as brain atrophy or the capacity atrophy, however, this patient did not need a contralateral
(elasticity) of the brain to compensate additional mass ef- reoperation and showed resorption of the hematoma with
fect. The possibility of compensation for a distinct hema- conservative treatment.
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FIG. 4. Graph illustrating the preoperative hematoma volume of the smaller, contralateral hematoma and the VR-ratio for all
patients. The horizontal dotted line indicates a hematoma volume of 40 cm3 and the vertical dotted line indicates a VR-ratio of 0.4.
Patients needing contralateral retreatment after an initially unilateral evacuation of their bcSDHs (group A, red) are almost entirely
located in the upper right portion of the graph, meaning that these patients showed a contralateral hematoma volume exceeding
40 cm3 and a VR-ratio of at least 0.4. Patients who underwent initially bilateral evacuation of their bcSDHs (green) are mainly
located in the upper right section, meaning larger hematomas on both sides. In the bottom left portion of the graph are mostly
patients who underwent unilateral evacuation and did not need contralateral retreatment (group B, blue). The upper left area is
nearly empty because this would indicate a condition in which the sum of both hematoma volumes would reach fatal levels. In
contrast, the right bottom portion is spared because locations there would indicate patients with hematoma volumes of less than
40 cm3 on each side. Such small hematomas would probably not cause any symptoms and therefore the patients would not have
needed surgical evacuation.

In contrast to that, 3 patients who needed subsequent eral retreatment after initial unilateral evacuation had a
contralateral retreatment after initial unilateral evacua- contralateral hematoma volume greater than 40 cm3 and
tion had small contralateral hematoma volumes of 41.0 a VR-ratio greater than 0.4 in the vast majority of cases.
cm3, 42.2 cm3, and 37.8 cm3 but VR-ratios of 0.52, 0.4, Such patients would probably have profited from initial bi-
and 0.44, respectively. The latter two patients addition- lateral evacuation.
ally were relatively young (21.7 and 56.9 years) and had While the VR-ratio is produced by dividing one hema-
no brain atrophy; despite having small bcSDHs, they had toma volume by the other, the ratio tries to characterize the
distinct mass effect. Figure 3 shows 2 other patients ini- pressure relation of the intracranial compartments in the
tially treated with unilateral hematoma evacuation. Their presence of bcSDHs. The benefit of the VR-ratio, there-
VR-ratio was at least 0.4, and both of them subsequently fore, depends on the surgical indication. In this retrospec-
needed contralateral retreatment. tive study, this decision was made by the neurosurgeon
Figure 4 shows the correlation between the volume of on duty and was based on the presence of mass effect in
the contralateral smaller hematoma and the VR-ratio in imaging studies and clinical symptoms. The decision of
patients who underwent unilateral or bilateral evacuation. whether or not bcSDHs should be treated surgically was
The figure illustrates how patients who needed contralat- not an issue of this study.
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Limitations 12. Rohde V, Graf G, Hassler W: Complications of burr-hole

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Conclusions al: Risk factors for reoperation after initial burr hole trephi-
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To date, the decision of whether to perform bilateral surg 138:66–71, 2015
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radiological parameters, but reproducible objective mea- changes in risk factors of chronic subdural hematoma. J
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subdural hematoma: what is the clinical significance? Int J The authors report no conflict of interest concerning the materi-
Surg 11:544–548, 2013 als or methods used in this study or the findings specified in this
8. Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N: Chronic paper.
subdural hematoma in elderly people: present status on Awaji
Island and epidemiological prospect. Neurol Med Chir (To- Author Contributions
kyo) 32:207–209, 1992 Conception and design: Scheichel. Acquisition of data: Scheichel,
9. Liu W, Bakker NA, Groen RJM: Chronic subdural hema- Popadic. Analysis and interpretation of data: Scheichel. Critically
toma: a systematic review and meta-analysis of surgical pro- revising the article: Marhold, Scheichel. Reviewed submitted ver-
cedures. J Neurosurg 121:665–673, 2014 sion of manuscript: Marhold, Scheichel, Ungersboeck. Approved
10. Nakaguchi H, Tanishima T, Yoshimasu N: Factors in the the final version of the manuscript on behalf of all authors: Mar-
natural history of chronic subdural hematomas that influence hold. Statistical analysis: Scheichel. Study supervision: Marhold.
their postoperative recurrence. J Neurosurg 95:256–262,
2001
11. Nakaguchi H, Tanishima T, Yoshimasu N: Relationship
Correspondence
between drainage catheter location and postoperative recur- Franz Marhold: University Hospital of St. Poelten, Lower Austria,
rence of chronic subdural hematoma after burr-hole irrigation Austria. [email protected].
and closed-system drainage. J Neurosurg 93:791–795, 2000

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