Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants

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OBJECTIVE

Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate.

METHODS

In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention.

RESULTS

Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement.

CONCLUSIONS

The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.

ABBREVIATIONS SDH = subdural hematoma.

Article Information

Correspondence Gregory W. Albert: Arkansas Children’s Hospital, Little Rock, AR. galbert2@uams.edu.

INCLUDE WHEN CITING Published online February 1, 2019; DOI: 10.3171/2018.11.PEDS18322.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Illustrations demonstrating the minicraniotomy technique. Left: The U-shaped incision is made just lateral to the anterior fontanelle such that the coronal suture is in the anterior-most portion of the skull exposure. A bone flap is created based on the coronal suture anteriorly, as shown. Right: The bone flap is elevated and reflected anteriorly. The dura is then opened widely to expose the subdural space.

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    Left: Representative CT scan before surgery of a patient with full resolution of the subdural fluid collection. Right: Representative CT scan 5 months postoperatively of a patient with full resolution of the subdural fluid collection.

  • View in gallery

    Left: Representative CT scan before surgery of a patient with incomplete resolution of the subdural fluid collection. Right: Representative CT scan 2 months postoperatively of a patient with incomplete resolution of the subdural fluid collection.

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