Endoscope-Assisted Evacuation of Acute-on-Chronic Subdural Hematomas: A Single-Center Series

Abstract

Purpose: Acute subdural hematomas are frequent, highly morbid, and affect all age groups. The most common mechanism of injury is a low-velocity fall, and the incidence of the disease is growing due to increasingly aggressive antithrombotic and anticoagulant therapies. In this study, we aimed to share our experience with the endoscopic-assisted evacuation of acute subdural hematoma, a less invasive procedure compared to standard craniotomy.

Methods: We retrospectively reviewed data of all consecutive patients aged 18 years and older who underwent endoscopic-assisted evacuation of acute-on-chronic subdural hematoma at our institution from 2015 to 2019. Preoperative, intraoperative, postoperative, and follow-up data were collected and reported. Statistical tests were done using Python statistical packages.

Results: Of the 35 patients that underwent this procedure, 32 were 18 years and older. The median age was 69.5 years and 37.5% were female. Twenty patients (62.5%) were on antiplatelet therapy, and six patients (18.75%) were on anticoagulants upon presentation. A fall was the most common cause of trauma (71.88%). The median operative time was 107 minutes. The median length of stay in days and Glasgow Coma Scale (GCS) at discharge were 8.5 and 15, respectively. There were no surgical site infections or in-hospital mortality in this series. At the latest follow-up, the median GCS and modified Rankin Scale were 15 and 1, respectively.

Conclusion: Evacuation of acute-on-chronic subdural hematomas can be performed safely and efficiently via a smaller craniotomy and with the assistance of an endoscope. This may represent a less invasive alternative than standard craniotomy/craniectomy in selected patients.

Keywords: endoscopy; hematoma; hematoma evacuation; subdural; trauma.

Figure 1. Endoscope-assisted subdural hematoma evacuation planning and intraoperative views

(A) Incision planned along the superior temporal line. (B) Small ovoid craniotomy with opened dura and exposed acute subdural hematoma. (C) Evacuation of immediately visible hematoma. (D) In-depth evacuation of hematoma and membranes along the cerebral convexity toward the floor middle fossa. (E) Hematoma evacuation and hemostasis are achieved.

Figure 2. Preoperative and postoperative computed tomography scans of the same patient with subdural hematoma

(A) Axial view of a computed tomography (CT) scan depicting an acute subdural hematoma of a patient from our series. (B) Axial view of a CT scan of the same patient in the immediate postoperative phase. (C) Axial view of a CT scan of the same patient during a follow-up visit four weeks after surgery.