The patient came to the clinic 13-November-2013 for check up for the evacuated chronic subdural hematoma performed 29-October-2013 for the first recurrence by inserting external drain. CT-scan done today showing accumulation of the hematoma as before the second admission.

On examination: the patient is in good condition with no paresis and he was going to the cardiologist for check up. It was explained the patient now needs craniotomy to radically remove the hematoma. The patient then came to the cardiologist and during that visit he progressed dysarthria with fainting attack and his BP was above 180/110 mm Hg. The patient was admitted to the ICU of Shmaisani hospital and investigations were done with correction of the BP. New MRI with contrast with MRA of the brain and carotids ruled out progression of new infarction.

In side lying position, craniotomy of the right fronto-parietal region, using the old burr holes. The skin was reflected to the right ear. The dura was opened and the thick membrane of the hematoma was followed and total resection of the hematoma with its membrane was achieved. The cortex was in good condition and the running arteries and veins in good shape with good cardio-pulmonary pulsation. The dura was water-tightly closed and one area of the dura was closed using glue with muscle to prevent CSF leak. Routine closure of the wound with ready vac drain under the skin.

Smooth postoperative recovery. The patient sent to the ICU.

The patient needs wide exposure with subsequent removal of the thick hematoma membranes.