The patient was operated by me 24-November-2014 for huge chronic subdural hematoma and the patient started to show slight recovery. The patient had several MRIs after surgery which showed persistence of the air in the subdural space and mild hematoma in the lower cavity. The patient was discharged 3 days ago and he showed deterioration, for what new MRI was done and showing recurrence of the huge hematoma.

On examination, the patient is better than during the first admission.

The old craniotomy was opened and the dura was opened now in T-shape fashion to regain better visual control. The haematoma was evacuated with its capsule. Considering that during first surgery the brain was not pulsating and it was lacking CSF flow, which is the cause of the hematoma recurrence, dissection of the sylvian cistern and other arachnoidal areas was performed to regain CSF flow and the brain started t pulsate and the subarachnoid spaces became CSF rich. Arachnoidolysis was continued until the brain started to expand and fill the space. A Medtronic external drain was inserted subdurally and water-tight closure of the dura. Ready vac drain inserted under the skin. Routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ICU for 4 days observation.

The patient has profound neurological deficit due to major shift of the brain and distortion of the anatomical structures, which will suffer even without direct compression.

The conning of the right hemisphere under the falx, made it impossible to make the hemisphere come back to its place. This was the cause of the rebleed.

Arachnoidolysis and dissection of the sylvian cistern and other possible subarachnoid spaces could promote reduction of the CSF flow and reestablishment of the cardio-pulmonary pulsation.