Abstract
INTRODUCTION: 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. RESEARCH QUESTION: This study evaluates the safety and effectiveness of TDC-FIT in reducing cSDH recurrence compared with standard approaches. METHODS: 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. RESULTS: 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. CONCLUSIONS: TDC-FIT demonstrated a favorable safety profile and substantially reduced recurrence compared with conventional techniques, supporting its integration as an effective minimally invasive alternative.