Endoscope-Assisted Evacuation of an Acute Subdural Hematoma in an Elderly Patient With Refractory Nonconvulsive Status Epilepticus: An Illustrative Case

Abstract

Traumatic brain injuries lead to post-traumatic seizures (PTS), with acute subdural hematomas (ASDH) posing a particularly elevated risk. The development of refractory nonconvulsive status epilepticus (NCSE) in such cases, especially in older patients, requires immediate and effective management. This case report highlights the improvement of refractory NCSE in an elderly patient with ASDH through endoscope-assisted evacuation. An 88-year-old woman was hospitalized for dysarthria and right hemiparesis 3 days after a fall. Computed tomography (CT) revealed a left hemispheric ASDH, 9 mm thick, along with minor traumatic subarachnoid bleeding in the interpeduncular cistern. The initial treatment was conservative, including the administration of lacosamide at 100 mg/day. However, her consciousness deteriorated 4 days after admission, and she experienced convulsions in the right face and arm on day 5. Although the convulsions stopped after the administration of diazepam 10 mg IV and her consciousness temporarily improved, it worsened again on day 6, leading to a diagnosis of NCSE on an electroencephalogram (EEG). Despite aggressive pharmacological interventions with fosphenytoin (750 mg initially followed by 262 mg/day) and phenobarbital (625 mg/day), the patient's cognitive state and EEG findings did not improve. Consequently, on the 13th day, she underwent an endoscopic procedure to remove the SDH, which alleviated her symptoms and ended the seizures. This case demonstrates that even the absence of a significant mass effect from ASDH can trigger NCSE, underscoring the necessity for swift diagnosis and consideration of surgical options when conventional treatment fails. Endoscope-assisted evacuation is a safe and effective treatment option, particularly in older patients.

Keywords: acute subdural hematomas; elderly; endoscopic assisted key hole surgery; non-convulsive status epilepticus; post-traumatic seizures.

Figure 1. Initial computed tomography imaging and magnetic resonance imaging

(A,B) Initial computed tomography (CT) images showing left hemispheric acute subdural hematoma (ASDH) (blue arrow) and mild traumatic subarachnoid hemorrhage in the interpeduncular cistern (white arrow). Magnetic resonance imaging (MRI) showing the same lesions, with hypointensity in the axial T2-weighted image (C). Additionally, MRI and CT showed hydrocephalus ex vacuo and the right predominant periventricular cerebrospinal fluid (CSF) leaks. No contusion or diffuse axis injuries were observed.

Figure 2. Electroencephalogram (EEG) findings

(A) EEG on day 4 shows repetitive ictal patterns arising from the left fronto-parietal area (black line). (B) EEG on day 11 shows repetitive ictal patterns arising from the midline area (dotted line).

Figure 3. Intraoperative findings

(A) A solid clot located in the subdural space is removed via a suction tube. (B) Subdural space after hematoma evacuation.

Figure 4. Postoperative computed tomography imaging

Axial computed tomography (CT) images 1 day after endoscopic surgery showing gross total hematoma evacuation (blue arrows).

Figure 5. Electroencephalogram after surgery

Electroencephalogram after surgery shows only intermittent slow waves in the left frontal area without any epileptiform discharges.