Choosing the best operation for chronic subdural hematoma: a decision analysis

Clinical article

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Chronic subdural hematoma (CSDH), a condition much more common in the elderly, presents an increasing challenge as the population ages. Treatment strategies for CSDH include bur-hole craniostomy (BHC), twist-drill craniostomy (TDC), and craniotomy. Decision analysis was used to organize existing data and develop recommendations for effective treatment.


A Medline search was used to identify articles about treatment of CSDH. Direct assessment by health care professionals of the relative health impact of common complications and recurrences was used to generate utility values for treatment outcomes. Monte Carlo simulation and sensitivity analyses allowed comparisons across treatment strategies. A second simulation examined whether intraoperative irrigation or postoperative drainage affect the outcomes following BHC.


On a scale from 0 to 1, the utility of BHC was found to be 0.9608, compared with 0.9202 for TDC (p = 0.001) and 0.9169 for craniotomy (p = 0.006). Sensitivity analysis confirmed the robustness of these values. Craniotomy yielded fewer recurrences, but more frequent and more serious complications than did BHC. There were no significant differences for BHC with or without irrigation or postoperative drainage.


Bur-hole craniostomy is the most efficient choice for surgical drainage of uncomplicated CSDH. Bur-hole craniostomy balances a low recurrence rate with a low incidence of highly morbid complications. Decision analysis provides statistical and empirical guidance in the absence of well-controlled large trials and despite a confusing range of previously reported morbidity and recurrence.

Abbreviations used in this paper: BHC = bur-hole craniostomy; CSDH = chronic subdural hematoma; TDC = twist-drill craniostomy.

Article Information

* Drs. Lega and Danish contributed equally to this study.

Address correspondence to: Bradley C. Lega, M.D., University of Pennsylvania, Department of Neurosurgery, Silverstein Pavilion, Floor 3, Philadelphia, Pennsylvania 19104. email:

Please include this information when citing this paper: published online October 30, 2009; DOI: 10.3171/2009.9.JNS08825.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Decision tree constructed using standard methodology. At each node in the tree, the probability of each of the possible outcomes is calculated. For recurrences, reoperations are allowed. Subsequent operations are not necessarily the same as the first.

  • View in gallery

    Graph illustrating the sensitivity analysis performed for CSDH with probability of recurrence plotted against mortality. The lines drawn represent calculated utility values for the complications associated with BHC (1 − disutility). These are the 3 variables identified as having the greatest impact on the overall utility of the management strategy. This graph illustrates that the variables would have to be drastically different than the reported values in the literature to make craniotomy or TDC the preferred strategy.



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