Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor

Abstract

Background: The first choice to treat acute subdural hematoma (ASDH) is large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategy inappropriate. These medically frail patients with ASDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive. We proposed covering with protective sheets to prevent brain injury due to contact with the endoscope and suction cannula and improve visualization of the subdural space. Moreover, we placed an intracranial pressure (ICP) sensor after endoscopic hematoma removal. In this article, we attempted to clarify the use of small craniotomy evacuation with endoscopy for ASDH.

Methods: Between January 2015 and December 2019, nine patients with ASDH underwent hematoma evacuation with endoscopy at our hospital. ASDH was removed using a suction tube with the aid of a rigid endoscope through the small craniotomy (5-6 cm). Improvement of the clinical symptoms and procedure-related complications was evaluated.

Results: No procedure-related hemorrhagic complications were observed. The outcomes of our endoscopic surgery were satisfactory without complications or rebleeding. The outcomes were not inferior to those of other reported endoscopic surgeries.

Conclusion: The results suggest that small craniotomy evacuation with endoscopy and postoperative management using an ICP sensor is a safe, effective, and minimally invasive treatment approach for ASDH in appropriately selected cases.

Keywords: Acute subdural hematoma; Endoscopic hematoma evacuation; Intracranial pressure; Minimally invasive; Small craniotomy; Surgical technique; Traumatic brain injury.

Figure 1:

(a) Three-dimensional computed tomography shows the cranial bone after the procedure. An approximately 8-cm linear skin incision was made parallel to the coronal suture, and small craniotomy of 5–6 cm in diameter was made on the point under which the hematoma thickness was largest. (b) Small craniotomy was performed at the thickest point of the hematoma to insert the endoscope.

Figure 2:

Intraoperative photograph showing a solid clot located between the dura mater and brain surface (a). The brain surface was covered with protective sheets to improve the visualization of the subdural space (b). Intraoperative photograph showing the area after hematoma evacuation (c).

Figure 3:

Illustrative schema of our procedure. (a) After a small 5-cm-diameter craniotomy and dural incision were made, a subdural hematoma just below and around the craniotomy is evacuated. (b) The brain surface is covered with protective sheets. A rigid endoscope and surgical instruments, such as a bipolar coagulator, suction cannula, or forceps, are inserted into the subdural space to evacuate the remaining subdural hematoma and stop bleeding.

Figure 4:

(a) Head computed tomography (CT) showing a thick acute subdural hematoma and mild midline shift at the time of admission in case 5. (b) Follow-up head CT showed sufficient hematoma removal and improved midline shift after the procedure.