Volumetric predictors of recurrence in chronic subdural hematomas: surgical technique comparison and 3D slicer-assisted volumetric analysis.

The objective of this study is to demonstrate the clinical applicability of 3D Slicer-assisted volume calculations through the analysis of results from single/burr-hole craniostomy (sBHC/dBHC), and mini-craniotomy procedures for the management of chronic subdural hematomas (cSDHs). A total of 163 patients with cSDH between January 1, 2020, and December 31, 2024, were admitted to our department. sBHC, dBHC or mini-craniotomy procedures were performed. Baseline characteristics, radiological features, and surgical and postoperative parameters were evaluated for all three procedures. Volumetric calculations were performed by employing 3D Slicer. Mini-craniotomy was performed in 67 patients (41.1%), sBHC in 54 (33.1%), and dBHC in 42 (25.8%). The overall recurrence rate was 20.9%, being lowest after mini-craniotomy (10.4%), followed by dBHC (19%) and sBHC (35.2%) (p = 0.004). Although mini-craniotomy achieved superior evacuation efficiency, surgical technique was not independently associated with recurrence after accounting for volumetric factors. In the primary model, each 10 mL increase in residual hematoma volume (RHV) increased the odds of recurrence ≈ 35-fold (p < 0.001). Both RHV and hematoma evacuation rate (HER) independently predicted recurrence, showing excellent discrimination (Area under the curve [AUC] = 0.965 and 0.961). Optimal cutoffs were ≈ 19 mL for RHV and 68% for HER, confirmed by cross-validation and sensitivity analyses. RHV and HER independently predicted recurrence, whereas surgical technique lost significance after accounting for these volumetric factors. Thresholds of ≈ 19 mL (RHV) and 68% (HER) may guide postoperative monitoring. 3D Slicer provides a simple, accessible tool for recurrence prediction in cSDH.