Awake surgery in sitting position for chronic subdural hematoma



Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification.


This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury.


Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period.


In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.

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We acknowledge the support of the Ministry of Education, Science and Technological Development of the Republic of Serbia, project TR 37001.

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Corresponding author

Correspondence to Lukas Rasulić.

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The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

Additional information


Chronic subdural hematoma (CSDH) is one of the most frequent neurosurgical diagnosis. Nevertheless, the optimal surgical technique is yet to be defined. In this technical note, the authors report on their preliminary experience with CSDH surgery in the sitting position, which they believe holds potential advantages to the patient as well as the surgeon. Furthermore, in their pilot series, the authors did not experience any case of air embolus or tension pneumocephalus—otherwise known as feared risk factors associated with neurosurgery in the sitting position. While additional research is needed to identify any pros and cons of this technique, this technical note adds to the discussion on the variety of CSDH surgical techniques, while illustrating the need of further studies to identify the optimal management of CSDH patients.

Jiri Bartek

Stockholm, Sweden

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Lepić, M., Mandić-Rajčević, S., Pavlićević, G. et al. Awake surgery in sitting position for chronic subdural hematoma. Acta Neurochir (2021).

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  • Chronic subdural hematoma
  • Craniostomy
  • Sitting position
  • Outcome
  • Reoccurrence