Membrane Tucking Technique using Ligature Clips with Intermembranous Placement of Oxidized Regenerated Cellulose in Multilayered Chronic Subdural Hematoma: Description of Novel Technique and our Initial Experience.

Chronic subdural hematoma (cSDH) is an encapsulated collection of blood and blood degradation products between dural border cell layers, the pathophysiology of formation and expansion of which is still debatable. It is usually seen in the elderly population, and surgical evacuation is the primary mode of treatment. The main hurdle in the treatment of cSDH is postoperative recurrences and the need for repeat operations. A few authors have classified cSDH into homogenous, gradation, separated, trabecular, and laminar types based on the internal architecture of hematoma and proposed that separated, laminar, and gradation types of cSDH have a high propensity of recurrence after surgery. A similar problem was described with multi-layered or multi-membrane cSDH. Based on the most accepted theory of formation and expansion of cSDH that suggests a complex and vicious process of membrane formation, chronic inflammation, neoangiogenesis, rebleeding from fragile capillaries, and increased fibrinolysis, we propose our theory of intermembranous placement of oxidized regenerated cellulose and membrane tucking using ligature clips to prevent recurrence in multi membranous cSDH by ceasing the ongoing cascade in hematoma's internal milieu and thus preventing recurrence and reoperation in such cases. This is the first in the world literature report describing such a technique for treating multi-layered cSDH and in our series, the reoperation and postoperative recurrence rates were 0% in patients treated by the described technique.