# Pressure-controlled fibrinolytic irrigation for membranous and recurrent chronic subdural hematomas

## TL;DR

A new minimally invasive treatment for chronic subdural hematomas significantly reduces recurrence, especially in high-risk membranous cases.

## Contribution

Pressure-controlled fibrinolytic irrigation (TDC-FIT) is introduced as a novel, effective treatment for high-risk chronic subdural hematomas.

## Key findings

- TDC-FIT reduced recurrence to 8.8%, significantly lower than conventional methods in membranous hematomas.
- TDC-FIT had a lower complication rate and better outcomes compared to open craniotomy and standard twist-drill craniostomy.
- Predictive models overestimated recurrence for TDC-FIT, indicating its effectiveness in high-risk cases.

## Abstract

Chronic subdural hematoma (cSDH) is a common neurosurgical condition with substantial recurrence after conventional evacuation. In June 2023, we introduced twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy (TDC-FIT), developed for patients at elevated recurrence risk.

This study evaluates the safety and effectiveness of TDC-FIT in reducing cSDH recurrence compared with standard approaches.

We performed a retrospective comparative analysis of all consecutive cSDH procedures from January 2021 to December 2024, including twist-drill craniostomy (TDC), open craniotomy (OC), and TDC-FIT. The primary endpoint was reoperation within six months for symptomatic recurrence or inadequate evacuation—defined as residual hematoma ≥10 mm, midline shift, or persistent symptoms. Secondary endpoints included perioperative complications and outcome.

A total of 779 procedures were performed in 491 patients: 698 TDC (89.6%), 40 OC (5.1%), 34 TDC-FIT (4.4%), and 7 others. Overall recurrence per procedure was 30.0%. Hematoma-related membranes strongly predicted recurrence (OR 3.4; p < 0.0001). Recurrence after TDC-FIT was 8.8%, significantly lower than TDC (30.1%) and OC (25.0%) (p = 0.024). In membranous hematomas, recurrence reached 45.0% after TDC, 24.3% after OC, and 9.7% after TDC-FIT (p = 0.001). Predictive modeling matched observed recurrence for TDC but markedly overestimated recurrence for TDC-FIT and OC. Adverse events were lowest after TDC (7.4%) and TDC-FIT (8.8%) and highest after OC (20.0%). Over time, practice shifted toward minimally invasive techniques with increasing adoption of TDC-FIT.

TDC-FIT demonstrated a favorable safety profile and substantially reduced recurrence compared with conventional techniques, supporting its integration as an effective minimally invasive alternative.

•Chronic subdural hematoma remains burdened by high recurrence despite conventional surgical treatment.•Patients with membranous hematomas are particularly vulnerable to recurrence and poor radiographic resolution.•Introducing TDC-FIT provides a targeted minimally invasive strategy for these high-risk cases.•TDC-FIT shows lower recurrence than twist-drill craniostomy or open craniotomy, even in membranous hematomas.•Its favorable safety profile and effectiveness are driving a progressive shift toward TDC-FIT in our clinical practice.

Chronic subdural hematoma remains burdened by high recurrence despite conventional surgical treatment.

Patients with membranous hematomas are particularly vulnerable to recurrence and poor radiographic resolution.

Introducing TDC-FIT provides a targeted minimally invasive strategy for these high-risk cases.

TDC-FIT shows lower recurrence than twist-drill craniostomy or open craniotomy, even in membranous hematomas.

Its favorable safety profile and effectiveness are driving a progressive shift toward TDC-FIT in our clinical practice.