J Neurosurg: Pediatrics / Volume 8 / November 2011 J Neurosurg Pediatrics 8:000–000, 2011 423 A persistent or chronic subdural collection—hy- groma or hematoma—in an infant is a common problem faced by pediatric neurosurgeons. These collections evolve from an acute hematoma or a tear in the arachnoid mater, usually precipitated by blunt force trauma (accidental or nonaccidental). 4,11 Less commonly, CSCs can be caused by a leptomeningeal infection or oc- cur spontaneously in patients with arachnoidomegaly. 28,29 Subdural collections can enlarge over time and cause ac- celerated head growth, compress the surrounding brain parenchyma, and produce focal or global neurological symptoms or defcits. J Neurosurg Pediatrics 8:423–429, 2011 Minicraniotomy versus bur holes for evacuation of chronic subdural collections in infants—a preliminary single-institution experience Clinical article P aul Klimo Jr., m.D., m.P.H., 1,2 anne mattHews, P.a.-C., 3 sean m. lew, m.D., 3 mariKe Zwienenberg-lee, m.D., 4 anD bruCe a. Kaufman, m.D. 3 1 Le Bonheur Children’s Hospital, and 2 Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee; 3 Department of Pediatric Neurosurgery, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and 4 Department of Neurosurgery, University of California–Davis, Sacramento, California Object. Various surgical interventions have been described to evacuate chronic subdural collections (CSCs) of infancy. These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. Shunt placement typically provides good long-term success (resolution of the subdural fuid), but comes with well-known early and late complications. Recently, the authors have used a mini– osteoplastic craniotomy technique with the goal of defnitively treating these children with a single surgery while avoiding the many issues associated with a shunt. They describe their procedure and compare it with the traditional bur hole technique. Methods. In this single-institution retrospective study, the authors evaluated 26 cases involving patients who underwent treatment for CSC. Preoperative, intraoperative, and postoperative data were reviewed, including radio- graphic fndings (density of the subdural fuid and ventricular and subarachnoid space size), neurological examina- tion fndings, and intraoperative fuid description. The primary outcome was treatment failure, defned as the patient requiring any subsequent surgical intervention after the index procedure (minicraniotomy or bur hole placement). Results. Fifteen patients (10 male and 5 female; median age 5.1 months) collectively underwent 27 minicra- niotomy procedures (each procedure representing a hemisphere that was treated). In the bur hole group, there were 11 patients (6 male and 5 female; median age 4.6 months) with 18 hemispheres treated. Both groups had subdural drains placed. The average follow-up for each treatment group was just over 7 months. Treatment failure occurred in 2 patients (13%) in the minicraniotomy group compared with 5 patients (45%) in the bur hole group (p = 0.09). Furthermore, the 2 patients who had treatment failure in the minicraniotomy group required 1 subsequent surgery each, whereas the 5 in the bur hole group needed a total of 9 subsequent surgeries. Eventually, 80% of the patients in the minicraniotomy group and 70% of those in the bur hole group had resolution of the subdural collections on the last imaging study. Conclusions. The minicraniotomy technique may be a superior technique for the treatment of CSCs in infants compared with bur hole evacuation. The minicraniotomy provides greater visualization of the subdural space and allows more aggressive evacuation of the fuid, better irrigation of the space, the ability to fenestrate any accessible membranes safely, and continued egress of fuid into the subgaleal space. Although this preliminary report has obvi- ous limitations, evaluation of this technique may be worthy of a prospective, multiinstitutional collaborative effort. (DOI: 10.3171/2011.8.PEDS1131) Key worDs • subdural hematoma • bur hole • minicraniotomy • infant • pediatric neurosurgery • nonaccidental trauma 423 Abbreviation used in this paper: CSC = chronic subdural collec- tion. This article contains some figures that are displayed in color online but in black and white in the print edition.