• Appukutty Manickam, Marshman Laurence A G LAG Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville, Queensland, Australia; School of Medicine, James Cook University, Doug, and Ross Johnston.
• Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville, Queensland, Australia.
• World Neurosurg. 2017 Apr 1; 100: 256-260.

BackgroundIt is unknown why some chronic subdural hematomas (CSDHs) grow and require surgery, whereas others spontaneously resolve. Although a relatively small CSDH volume (V) reduction may induce resolution, V percent reduction is often unreliable in predicting resolution. Although CSDHs evolve distinctive inner neomembranes and outer neomembranes (OMs), the OM likely dominates the dynamic growth-resorption equilibrium. If other factors remain constant, one previous hypothesis is that resorption could fail as the surface area (SA) to V ratio decreases when CSDHs exceed a critical size. We aimed to identify a critical size and an ideal target, which implies resolution without recurrence.MethodsThree-dimensional computed tomography CSDH SA to V ratios were obtained using computer software to compare CSDH SA to V between cases requiring surgery (surgical) and cases managed conservatively with spontaneous resolution (nonsurgical).ResultsData were obtained in 45 patients (surgical: n = 28; nonsurgical: n = 17). CSDH risk factors did not significantly differ between surgical and nonsurgical cases. Surgical V was 2.5× the nonsurgical V (119.9 ± 33.1 mL vs. 48.4 ± 27.4 mL, respectively; P < 0.0001). Surgical total SA was 1.4× nonsurgical SA (256.63 ± 70.65 cm2 vs. 187.67 ± 77.72 cm2, respectively; P = 0.004). Surgical total SA to V ratio was approximately one half that of nonsurgical SA to V ratio (2.14 ± 0.90 mL-1 vs. 3.88±1.22 mL-1, respectively; P < 0.0001). Surgical OM SA (SAOM) was 120.63 ± 52 cm2, and nonsurgical SAOM was 94.10 ± 41 cm2 (P < 0.0001). Nonsurgical SAOM to V ratio was 1.94 mL-1, whereas surgical SAOM to V ratio was 1.005 mL-1 (i.e., surgical SAOM ≈ V).ConclusionsBecause surgical total SA to V ratio was ≈2:1, one neomembrane may indeed dominate the dynamic growth-resorption equilibrium. CSDH critical size therefore appears to be when SAOM ≈ V, which is intuitive. Practically, subtotal CSDH evacuation which approximately doubles total SA to V ratio or SAOM to V ratio implies CSDH resolution without recurrence. This could guide subdural drain removal timing, discharge, or transfer. Prospective validation studies are required.Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

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