Preoperative Planning for Burr Hole Surgery in Chronic Subdural Hematoma: Visualization of the Superficial Temporal and Middle Meningeal Arteries Using Noncontrast CT

Abstract

Objectives

Recent developments in volume rendering techniques have enabled soft-tissue visualization using noncontrast computed tomography (CT). We aimed to visualize the superficial temporal artery (STA) and middle meningeal artery (MMA) using noncontrast CT to evaluate the technique's usefulness in preoperative planning for chronic subdural hematoma (CSDH).

Materials and Methods

We examined 99 hemispheres of 83 patients with CSDH who underwent burr-hole surgery between August 2019 and May 2023. Of these, 61 hemispheres were preoperatively planned. In the planned group, the STA and MMA were visualized using volume rendering on noncontrast CT scans, and burr-hole positions were planned accordingly to avoid these vessels. This study compared injury rates to the main and secondary branches of the STA and MMA between the planned and nonplanned groups. Postoperative complications including acute intracranial bleeding, subcutaneous hematoma, and CSDH recurrence were investigated.

Results

STA injury rate was significantly lower in the planned group than in the nonplanned group (21.3 vs. 42.1%, p = 0.027). Similarly, the MMA injury rate was lower in the planned group than in the nonplanned group (36.1 vs. 55.3%, p = 0.061). No cases of postoperative intracranial bleeding were observed, and hematoma recurrence rate did not significantly differ between the groups.

Conclusion

Preoperative evaluation of the STA and MMA using volume rendering from noncontrast CT is technically feasible. This approach may reduce vessel injury, particularly to branches, in burr-hole surgery for CSDH; however, further studies are needed to determine its clinical significance.

Keywords

chronic subdural hematoma - burr-hole surgery - superficial temporal artery - middle meningeal artery - volume rendering

Introduction

Chronic subdural hematoma (CSDH) is a common neurosurgical disease, which is predominantly reported in older adults. The annual incidence of CSDH is 8.2 to 14 per 100,000 person-years.[1] Surgical treatment is recommended for patients with CSDH presenting with neurological symptoms, and the preferred surgical technique is burr-hole drainage.[2] [3] According to Mori and Maeda, the most frequent complication is acute subdural hematoma (2.6%), which is a result of bleeding at the scalp wound, causing fresh blood to flow directly into the evacuated subdural space. Those authors emphasized the importance of careful hemostasis of scalp wounds during surgery.[4] The superficial temporal artery (STA) is the main source of blood supply to the scalp, and the middle meningeal artery (MMA) is the main source of blood supply to the dura mater. Avoiding intraoperative injury to the STA and MMA is considered important for preventing postoperative hemorrhage.

Given that the STA can be visualized using a contrast agent, previous studies have attempted to preserve it during craniotomy using three-dimensional computed tomographic angiography (CTA).[5] However, contrast-enhanced computed tomography (CT) is not routinely performed for patients with CSDH. Recent developments in volume rendering (VR) techniques have enabled soft-tissue visualization on noncontrast CT scans, but reports on the efficacy of this approach in neurosurgical planning remain limited.

MMA vessels penetrate the dura and sometimes run intraosseously.[6] Neurosurgeons often encounter MMA bleeding when performing burr-hole surgery, which increases the risk for intra- and postoperative bleeding. MMA can be confirmed by VR of noncontrast CT.[7]

Therefore, we aimed to investigate the feasibility of preoperative plain CT for visualizing the STA and MMA in patients with CSDH and evaluate its usefulness for preoperative planning.

Materials and Methods

Participants

This study was approved by the Institutional Review Board of our hospital (approval number: TEIRIN No. 19–229) and was performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients. Eighty-three patients (99 hemispheres) with CSDH who underwent burr-hole surgery between August 2019 and May 2023 at our hospital were included. All patients were diagnosed based on CT scanning results. Hematoma location was identified as left-sided, right-sided, or bilateral. Demographic data, including patient sex, age at surgery, and follow-up duration, were obtained from medical charts.

Imaging Protocol

We performed noncontrast CT pre- and postoperatively using a multidetector-row CT scanner (LightSpeed VCT and REVOLUTION EVO; GE Healthcare, Chicago, Illinois, United States). The scanning parameters included axial scan, 120-kV tube voltage, 360-mA tube current, 1.0-second rot rotation time, standard reconstruction function, 5-mm slice thickness, 5-mm slice interval, and a 32-cm scan field of view.

Image Postprocessing

Among the 83 patients and 99 hemispheres mentioned, preoperative surgical planning was done for 61 hemispheres in 54 patients (planned group), and for 38 hemispheres in 29 patients (nonplanned group) surgery was conducted without planning. Group allocation was based on the individual surgeon's judgment. The detailed preoperative planning methods are described below.

Advantage Workstation 4.7 (GE Healthcare) software was used as the image processing workstation. CT images were reconstructed using VR. The VR images were adjusted to visualize the soft tissue. [Fig. 1] illustrates the detailed parameters and the VR images. These parameters include setting the opacity to 0% at the CT value of ̶200 Hounsfield units (HU) and adjusting it to 40 to 50% at the CT value of 750 HU. The opacity curve was set to “Ramp up.” The color tone was set to “beige” at a CT value of 35 HU, “yellow” at 50 HU, “red” at 150 HU, and “white” at 250 HU. The color transition was set to “smooth.” The brightness was set to 100%. The transparency was adjusted to make the soft tissue visible ([Fig. 1A]). We registered these settings as presets for easy execution. Using this method, we successfully visualized the STA on the scalp using a noncontrast CT scan ([Fig. 1B]). The STA was ultimately identified based on its anatomical course, ascending anterior to the external auditory meatus over the zygomatic arch and dividing into the frontal and parietal branches. Subsequently, by generating three-dimensional bone images using VR bone mode and virtually cutting the skull on the unaffected side, we observed the MMA on the affected side from inside ([Fig. 1C]). The MMA was identified by its characteristic groove leading to the foramen spinosum. While examining the extent of the hematoma on the original CT axial images, we set the burr-hole positions to avoid these vessels in the planned group. As part of the preoperative planning position, a circular cut was made at the specified position and the images were saved ([Fig. 2]). We established a clear correlation between the planning position and the anatomical landmarks on the body surface including the coronal suture, linea temporalis, external auditory meatus, and lateral orbital rim, and recorded the distances from the planning position to each of these landmarks. All surgeons followed the same workflow and applied the same anatomical criteria for vessel identification, minimizing interoperator variability.

Fig. 1 Detailed parameters of volume rendering images, and visualization of the superficial temporal artery (STA) and middle meningeal artery (MMA) using noncontrast computed tomography (CT). (A) Detailed parameters of imaging protocols. Opacity was set to 0% at the CT value of ̶200 Hounsfield units (HU), and 40–50% at the CT value of 750 HU. Opacity curve was set to “ramp up.” Color tone was set to “beige” at CT value 35 HU, “yellow” at 50 HU, “red” at 150 HU, and “white” at 250 HU. Color transition was “smooth,” and brightness was 100%. Transparency was adjusted so that the soft tissue could be seen. (B, C) STA (blue arrowhead) and MMA (red arrowhead) were visualized on the left side using volume rendering.

Fig. 2 Preoperative planning of burr-hole position to avoid the superficial temporal artery (STA) and middle meningeal artery (MMA). Axial image of the CSDH (A), bone VR image (B), VR image visualizing the STA (C), and VR image visualizing the MMA (D). A circular cut (black circle) was used for preoperative planning position. The axial image confirms the presence of a black circle on the hematoma. The positional relationship between the planning position and anatomical landmarks, such as the coronal suture (blue dotted line), was clarified. The planning position was set to avoid STA (blue arrowhead) and MMA (red arrowhead). CSDH, chronic subdural hematoma; VR, volume rendering.

Surgical Technique

In the operating room, burr-hole positions in the planned group were identified with reference to the positional relationships and measured distances to these anatomical landmarks. By contrast, in the nonplanned group, the perforation position was determined by confirming the extent of the hematoma as viewed on the original CT image. A skin incision of ∼4 to 5 cm was made directly above the burr hole. Any bleeding from the STA or STA amputation was recorded. STA bleeding was controlled by coagulation. Subsequently, a hand drill was used to open the burr hole, and any bleeding from the MMA was similarly recorded. MMA bleeding was controlled using coagulation, or by applying a hemostatic agent, or bone wax. Following these procedures, the dura mater and hematoma outer membrane were incised, a drainage tube was inserted, the hematoma was aspirated, and the evacuated subdural space was irrigated using normal saline. A subdural drain was inserted, and the skin incision was closed using surgical staples. The subdural drain was left overnight and removed the day after surgery.

Data Analysis

A routine CT scan was taken a day after the surgery. We investigated the STA and MMA injury rates in the planned and nonplanned groups using fused CT images and intraoperative findings. The STA is typically a terminal branch of the external carotid artery and is commonly divided into frontal and parietal branches.[8] For this study, the “main branches” of the STA were defined as the frontal and parietal branches, whereas “secondary branches” referred to subdivisions arising from the main branches. For the MMA, the “main branch” was defined as the main convexity branch, and “secondary branches” were defined as divisions arising from it. We assessed if the skin incision crossed the STA by fusing the pre- and postoperative images. The skin incision location was identified using skin staples. We evaluated any damage to the MMA due to the burr hole using postoperative VR images. Bleeding or amputation of the main or secondary branches of the STA and MMA were assessed using intraoperative findings.

Second, distance between the planned and actual burr-hole position (d) was measured on the fused image and recorded. In the planned group, a subgroup analysis was conducted for patients for whom the d-value was smaller than the median value, and the injury rates of the STA and MMA were analyzed.

Finally, we investigated postoperative complications including acute intracranial bleeding, acute subcutaneous hematoma, and CSDH recurrence.

Statistical analyses were conducted using Student's t-test for continuous variables and the chi-squared test for categorical variables. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP Pro 18.1.0 software (SAS Institute, Cary, North Carolina).

Data Availability

Data on the study findings are available from the corresponding author upon reasonable request.

Results

Patient Characteristics

A total of 83 patients and 99 hemispheres were included in this study. [Table 1] summarizes the patient characteristics. The median age of the cohort was 78 years (IQR: 72–84 years), and 63 patients (75.9%) were men. In the planned group, the median age was 78 years (IQR: 71–83 years), and 40 patients (74.1%) were men. In the nonplanned group, the median age was 79 years (IQR: 75–84 years), and 23 patients (79.3%) were men. CSDH was more frequently observed on the left side (42.2%), followed by the right side (38.6%), and both sides (19.3%). In the nonplanned group, bilateral hematomas were significantly more frequent. The median follow-up period for all patients was 57 days (IQR: 32–152 days), with 71 days (IQR: 36–238 days) in the planned group and 38 days (IQR: 30–80 days) in the nonplanned group.

Table 1 Baseline characteristics of 83 patients with chronic subdural hematoma

	All patients	Planned group	Nonplanned group	p-Value
No. of patients	83	54	29
Hemispheres	99	61	38
Age, median [IQR], years	78 [72–84]	78 [71–83]	79 [75–84]	0.139
Male (%)	63 (75.9%)	40 (74.1%)	23 (79.3%)	0.595
Hematoma location
Unilateral	67 (80.7%)	47 (87.0%)	20 (69.0%)	0.047
Left side	35 (42.2%)	25 (46.3%)	10 (34.5%)
Right side	32 (38.6%)	22 (40.7%)	10 (34.5%)
Bilateral	16 (19.3%)	7 (13.0%)	9 (31.0%)	0.047
Follow-up period, median [IQR], days	57 [32–152]	71 [36–238]	38 [30–80]	0.068

Abbreviations: IQR, interquartile range; No., number.

Planned Group

In the planned group, the STA and MMA could be visualized in all patients using preoperative noncontrast CT images. For 53 hemispheres (86.9%), the burr hole was successfully positioned on the hematoma avoiding both the STA and MMA. In six hemispheres (9.8%), the MMA branches were anatomically unavoidable and the planned burr holes were set only to avoid the STA. In two hemispheres (3.3%), STA branches were unavoidable, and the burr holes were set only to avoid the MMA.

The difference between the preoperative planned burr-hole position and the actual burr-hole position (d) was measured by fusing the pre- and postoperative images. The median distance was 15 mm (IQR: 9.5–22.1 mm).

STA and MMA Injury

The STA main branch was injured for nine hemispheres (14.8%) in the planned group and six (15.8%) in the nonplanned group, with no significant difference between groups (p = 0.89). Conversely, the STA main and/or secondary branches were injured in 13 (21.3%) and 16 (42.1%) hemispheres in the planned and nonplanned groups, respectively, which was significantly lower in the planned group (p = 0.027) ([Table 2], [Fig. 3A]).

Table 2 Superficial temporal artery (STA) and middle meningeal artery (MMA) injury rates in the planned and nonplanned groups

	All hemispheres	Planned group	Planned group (d ≤ 15 mm)	Nonplanned group
STA injury
Main branch (%)	15 (15.2%)	9 (14.8%)	3 (9.7%)	6 (15.8%)
p-Value (vs. nonplanned group)		0.889	0.453
Main and/or secondary branches (%)	29 (29.3%)	13 (21.3%)	5 (16.1%)	16 (42.1%)
p-Value (vs. nonplanned group)		0.027[a]	0.020[a]
MMA injury
Main branch (%)	25 (25.3%)	14 (23.0%)	7 (22.6%)	11 (29.0%)
p-Value (vs. nonplanned group)		0.504	0.549
Main and/or secondary branches (%)	43 (43.4%)	22 (36.1%)	11 (35.5%)	21 (55.3%)
p-Value (vs. nonplanned group)		0.061	0.101

^a Statistical significance (p < 0.05).

Fig. 3 Injury rates of superficial temporal artery (STA) and middle meningeal artery (MMA) in planned and nonplanned groups. (A) STA main and/or secondary branches injury rate was significantly lower in the planned group compared with that in the nonplanned group. In the planned group with d ≤ 15 mm, the injury rate was even lower. (B) MMA main and/or secondary branches injury rate tended to be lower in the planned group and in patients with d ≤ 15 mm compared with that in the nonplanned group.

The MMA main branch was injured in 14 hemispheres (23.0%) in the planned group and 11 (28.9%) in the nonplanned group, with no significant difference between the groups (p = 0.48). However, the MMA main and/or secondary branches were injured in 22 (36.1%) and 21 (55.3%) hemispheres in the planned and nonplanned groups, respectively, with a tendency to be lower in the planned group (p = 0.061) ([Table 2], [Fig. 3B]).

Additionally, in the planned group, a subgroup analysis was performed on patients in whom the distance between the planned and actual burr-hole positions (d) was ≤15 mm. The STA main and/or secondary branches were injured in five hemispheres (16.1%), which was significantly lower than in the nonplanned group (p = 0.020) and was lower than in the overall planned group. The MMA main and/or secondary branches were injured in 11 hemispheres (35.5%), which was lower than in the overall planned group ([Table 2], [Fig. 3]).

Postoperative Complications

None of the patients in both groups experienced postoperative acute intracranial hemorrhage including acute subdural hemorrhage or subcutaneous hematoma. CSDH recurrence occurred in 10 hemispheres overall (10.1%); five hemispheres in the planned group (8.2%) and five hemispheres in the nonplanned (13.2%) group. However, there were no significant intergroup differences (p = 0.43).

Discussion

Findings from this prospective study showed that STA and MMA could be visualized using noncontrast CT and that preoperative planning may reduce vessel injury, particularly to branches, in burr-hole surgery for CSDH. To the best of our knowledge, no study has reported on the visualization of scalp blood vessels using noncontrast CT or evaluated its clinical usefulness.

Based on the recent advancements in image reconstruction technology, numerous studies have reported that VR using contrast-enhanced imaging helps in understanding head anatomy and surgical planning.[5] [9] The STA is a terminal branch of the external carotid artery and is commonly divided into the frontal and parietal branches.[8] This artery ascends through the zygomatic arch's lateral posterior margin to reach the temporal region of the scalp, supplying the muscles and skin.[10] Several studies have used VR with contrast-enhanced three-dimensional CT to visualize the STA and its branches[9] and to assess its anatomy.[11] Kuruoglu et al demonstrated that three-dimensional CTA with VR for frontotemporal craniotomy preserved the STA, prevented skin problems due to insufficient blood supply, and enabled its use for future cranial anastomosis surgery.[5] Hayashi et al. reported that magnetic resonance bone-vessel fused VR imaging noninvasively depicted STA frontal branches with better visibility than did CT-based imaging, and was useful for preoperative evaluation of donor branches for STA–middle cerebral artery bypass surgery.[12]

Most previous studies have used contrast agents, and few have visualized scalp vessels using noncontrast CT. In the scalp, vascular structures such as the STA have greater CT contrast than the surrounding subcutaneous tissue; therefore, VR can successfully visualize the STA by utilizing the differences in CT values. The MMA was visualized by identifying its position from the vascular groove.

Mori and Maeda reported that acute subdural hematoma is a frequent postoperative complication caused by bleeding from the scalp wound.[4] Rauhala et al reported that acute intracranial hemorrhage is rare, with postoperative acute subdural hemorrhage occurring in 1.1% of cases, some of which required craniotomy.[13] Other studies have also reported post-operative acute subdural hemorrhage as a serious surgical complication in CSDH.[14] [15] [16] [17] The STA supplies the scalp and the MMA supplies the dura mater; avoiding their intraoperative injury is considered important to prevent postoperative hemorrhage.

In this study, the preoperatively planned group had a significantly lower rate of injury to the STA main and/or secondary branches, and there was a trend toward fewer injuries to the MMA main and/or secondary branches in the planned group. However, no significant differences were observed in postoperative bleeding, which was likely owing to its very low incidence. Nevertheless, reduced intraoperative vascular injury may help decrease unexpected bleeding, improve visualization, and shorten operative time. Therefore, further large-scale studies are needed to determine the impact of preoperative planning on clinical outcomes. Furthermore, this technique may be useful in emergency craniotomy or in cases where only noncontrast CT is available, such as in patients who cannot receive contrast agents or undergo MRI, as it may help avoid scalp vessel injury and reduce intraoperative bleeding or wound-related complications.

In the planned group, the STA and MMA could not be completely avoided in some cases, which was because of discrepancies between preoperative planning and actual burr-hole positions. A subgroup analysis of patients with a smaller d-value showed an even lower rate of STA and MMA injury, supporting this interpretation. Therefore, a navigation system or preoperative marking could improve accuracy and reduce the risk of vascular injury.

In this study, we planned surgery to avoid injury to the MMA to reduce the risk of intraoperative and postoperative bleeding. However, MMA embolization through endovascular intervention has emerged as a promising treatment for CSDH, and numerous studies have verified its efficacy and safety.[18] [19] [20] [21] [22] Surgical occlusion of the MMA has also been reported.[7] Further research is needed to evaluate both the risks and potential benefits of MMA injury.

Our study has a few limitations. The patients were not randomized, and the decision to perform preoperative planning was influenced by the operators' judgment, which may have introduced selection bias. Additionally, given the involvement of multiple operators, the possibility of interoperator variation could not be excluded. Finally, this was a single-center study with a relatively small sample size, which may limit the generalizability of the findings. To overcome these limitations, large randomized controlled trials with standardized surgical techniques are warranted.

Conclusion

Our study demonstrated that STA and MMA can be visualized using VR reconstruction of noncontrast CT images. Preoperative planning based on this technique may reduce vessel injury to the STA and MMA, particularly to branches, in burr-hole surgery for CSDH; however, no significant differences were observed in postoperative bleeding or recurrence rates. The main value of this approach lies in its technical feasibility, and further studies are warranted to clarify its impact on clinical outcomes.

Conflict of Interest

None declared.

Authors' Contributions

T.H. contributed to conceptualization, data curation, investigation, visualization, and writing the original draft. H.N. and A.I. were involved in investigation, formal analysis, and writing, reviewing, and editing the manuscript. Y.I. contributed to investigation, formal analysis, supervision, and writing, reviewing, and editing. S.N., K.Y., H.M., R.Y., H.O., and T.Y. contributed to data curation and writing, reviewing, and editing. K.H. contributed to conceptualization, formal analysis, methodology, project administration, supervision, and writing, reviewing, and editing. All authors have read and approved the final manuscript.

Ethical Approval

This study was approved by the institutional review board of our hospital (approval number: TEIRIN No. 19–229) and was performed in accordance with the principles of the Declaration of Helsinki.

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Publication History

Article published online:
03 February 2026