Flexible endoscopically assisted evacuation of acute and subacute subdural hematoma through a small craniotomy: preliminary results

Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor

BACKGROUND

Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation.

METHODS

A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed.

RESULTS

The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality.

CONCLUSIONS

Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.

Successful Management of Acute Subdural Hematoma in Deep Brain Stimulation Patient: A Case Report and Literature Review

Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.

Endoscopic evacuation of chronic subdural hematoma with rigid and flexible endoscope: case report

Introduction

Subdural haematoma (SDH) is a common neurosurgical condition after head trauma requiring evacuation to prevent secondary brain injury. The first choice of management in these patients is a large craniotomy or burr-hole evacuation. However, sometimes due to lack vision during drain tube insertion or irrigation the authors might land up in a complication like cortical bridging vein rupture, haemorrhage etc. Also, the management of septate chronic SDH (CSDH) with multiple neo-membranes does not have a well-defined surgical approach. Recently, endoscopic evacuation has been reported to a be a feasible method for evacuation in acute, subacute and chronic SDH patients.

Presentation of case

A 65-years-old male patient presented with a history of recent head injury and symptoms of headache and urinary incontinence of 7 days (Glasgow Coma Scale Score 15/15). Computed tomography scan revealed CSDH at both fronto-parietal convexity more on right side.

Discussion

The authors reported our initial experience on a typical case of an older patient with chronic subdural haematoma and its evacuation with the assistance of both rigid and flexible endoscope. The authors could visualize cortical bridging veins and neo-membranes intraoperatively and guided our drainage tube accordingly to avoid inadvertent haemorrhage. There was no recurrence of symptoms postoperatively. Thus we achieved apparent successful evacuation of the CSDH in this patient in a 6-month follow-up.

Conclusion

Endoscopic evacuation of CSDH proves to be an effective minimally invasive modality and more studies are required on larger patient groups with long-term follow-up imaging to confirm its superiority.

The interdural hematoma: A subtype of convexity subdural/dural hematoma with specific radioanatomical characteristics

Background

Rare cases of biconvex hematomas splitting the convexity dura mater were reported and denominated interdural hematoma (IDH). Due to their rarity, little is known about their radiological characteristics, and in most cases, their invasive management with craniotomy and dural membrane excision is unnecessary.

Case Description

We report here a case of single burr-hole endoscopic evacuation of an IDH and its complete resolution after the 6-month follow-up imaging. The literature review reveals 11 reported cases of IDH. Most of them are male and the mean age is 65 years (range 51-90). Most of the reported IDHs were misdiagnosed as epidural hematoma or meningioma, and therefore, they have been managed invasively through craniotomy with dural excision. Diagnosis of the interdural nature was confirmed macroscopically during surgery in all cases and histology was reported for 6 cases. Image analysis found a double dural beak sign and biconvex shape on coronal planes, subarachnoid space enlargement at the collection extremities, and irregular thick inner wall as common radiological aspects of the IDH.

Conclusion

IDH is a rarely reported and often misdiagnosed dural hematoma subtype. Its invasive treatment through craniotomy is likely related to its unknown radiological characteristics. We review and raise awareness about potentially unique radiological anatomy that could avoid unnecessary invasive treatment. Moreover, we report the first case of endoscopically evacuated IDH with long-term follow-up imaging showing complete resolution.

Endoscopic Treatment of Chronic Subdural Hematoma Combined with Inner Subdural Hygroma

OBJECTIVE

A chronic subdural hematoma (CSDH) is a collection of bloody fluid located in the subdural space and encapsulated by neo-membranes. An inner subdural hygroma (ISH) is observed between the inner membrane of a CSDH and the brain surface. We present six cases of CSDH combined with ISH treated via endoscopy.

METHODS

Between 2011 and 2022, among the 107 patients diagnosed with CSDH in our institute, six patients were identified as presenting with CSDH combined with ISH and were included in this study. Preoperative computerized tomography (CT) and magnetic resonance imaging (MRI) were performed simultaneously, and endoscopic surgery for aspiration of the hematoma was performed in all cases of CSDH combined with ISH.

RESULTS

The mean age of patients was 71 years (range, 66 to 79). The patients were all male. In two cases, the ISH was not identified on CT, but was clearly seen on MRI in all patients. The inner membrane of the CSDH was tense and bulging after draining of the CSDH in endoscopic view due to the high pressure of the ISH. After fenestration of the inner membrane of the CSDH and aspiration of the ISH, the membrane was sunken down due to the decreasing pressure of the ISH. There was one recurrence in post-operative 2-month follow up. The symptoms improved in all patients after surgery, and there were no surgery-related complications.

CONCLUSION

CSDH combined with ISH can be diagnosed on imaging, and endoscopic surgery facilitates safe and effective treatment.

Endoscope-Assisted Keyhole Surgery for Traumatic Subacute Subdural Hematoma Evacuation in Emergencies

OBJECTIVE

This study aimed to investigate whether a simple endoscopic method was effective for the evacuation of traumatic subacute subdural hematomas.

METHODS

A total of 51 patients with subacute subdural hematomas requiring surgery were enrolled in this study. An endoscopic hematoma evacuation was performed through a small bone window for 22 patients. Hematoma evacuation by open surgery was performed for 29 patients. The postoperative Glasgow Coma Scale scores improvement, surgery times, displacement of midline measurements, and intraoperative blood loss were recorded and analyzed for each patient.

RESULTS

The average time from the initial incision to suture completion was 38.41 ± 6.97 minutes for the endoscopic surgery group and 74.66 ± 9.54 minutes for the open-surgery group (P < 0.01). The average total blood loss was 41.36 ± 10.82 ml for the endoscopic group and 250.00 ± 58.25 ml for the open-surgery group (P < 0.01). No postoperative bleeding occurred in either group. The midline displacement measurement showed significant improvement on the day after surgery, with 5.21 ± 1.98 mm in the study group versus 6.75 ± 1.37 mm in the control group (P < 0.01). At the 1-month follow-up appointment, the midline measurement was normal in both groups. Computed tomography scans revealed almost no residual hematomas, representing an average evacuation rate of 100% in both groups. The average Glasgow Coma Scale scores improvement on the day after surgery were 1.77 ± 1.93 in the endoscopic surgery group and 1.66 ± 0.77 in the open-surgery group (P = 0.766).

CONCLUSION

Endoscopic subacute subdural hematoma removal through a small bone window achieved satisfactory hematoma removal using a minimally invasive method when compared with an open-surgery method.

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

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.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

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

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.

Less Invasive Management of Endovascular Embolization and Neuroendoscopic Surgery for a Dural Arteriovenous Fistula Presenting with Acute Subdural Hematoma

Acute subdural hematoma (ASDH), which causes midline shift of the brain, rarely arises from a dural arteriovenous fistula (DAVF). Herein, we report the first case of a DAVF manifesting ASDH, which was treated less invasively with endovascular embolization of a drainer of the DAVF and hematoma removal under neuroendoscopy. A 59-year-old man with a sudden onset of headache was transported to our hospital. Left ASDH and intracerebral hematoma in the left occipital lobe were detected. A cerebral angiogram revealed a DAVF fed by the petrosquamous branch of the left middle meningeal artery and jugular branch of the right ascending pharyngeal artery. The shunting point in the lateral tentorial DAVF drains through the internal occipital vein to the superior sagittal sinus. A varix was recognized in the draining vein (Borden type 3, Cognard type 4). The DAVF was embolized with Onyx (Medtronic, Minnesota, USA), and the left ASDH was removed with a small craniotomy under neuroendoscopy. No origin of the left ASDH was apparent in the surgical field. The patient was discharged from the hospital on postoperative day 18. The patient's status was modified Rankin scale 1 on discharge. Our management of combined endovascular treatment and neuroendoscopic hematoma removal may be useful and less invasive for hemorrhagic DAVF.

The role of frailty in the clinical management of neurofibromatosis type 1: a mixed-effects modeling study using the Nationwide Readmissions Database

OBJECTIVE

Frailty embodies a state of increased medical vulnerability that is most often secondary to age-associated decline. Recent literature has highlighted the role of frailty and its association with significantly higher rates of morbidity and mortality in patients with CNS neoplasms. There is a paucity of research regarding the effects of frailty as it relates to neurocutaneous disorders, namely, neurofibromatosis type 1 (NF1). In this study, the authors evaluated the role of frailty in patients with NF1 and compared its predictive usefulness against the Elixhauser Comorbidity Index (ECI).

METHODS

Publicly available 2016–2017 data from the Nationwide Readmissions Database was used to identify patients with a diagnosis of NF1 who underwent neurosurgical resection of an intracranial tumor. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator. ECI scores were collected in patients for quantitative measurement of comorbidities. Propensity score matching was performed for age, sex, ECI, insurance type, and median income by zip code, which yielded 60 frail and 60 nonfrail patients. Receiver operating characteristic (ROC) curves were created for complications, including mortality, nonroutine discharge, financial costs, length of stay (LOS), and readmissions while using comorbidity indices as predictor values. The area under the curve (AUC) of each ROC served as a proxy for model performance.

RESULTS

After propensity matching of the groups, frail patients had an increased mean ± SD hospital cost ($85,441.67 ± $59,201.09) compared with nonfrail patients ($49,321.77 ± $50,705.80) (p = 0.010). Similar trends were also found in LOS between frail (23.1 ± 14.2 days) and nonfrail (10.7 ± 10.5 days) patients (p = 0.0020). For each complication of interest, ROC curves revealed that frailty scores, ECI scores, and a combination of frailty+ECI were similarly accurate predictors of variables (p > 0.05). Frailty+ECI (AUC 0.929) outperformed using only ECI for the variable of increased LOS (AUC 0.833) (p = 0.013). When considering 1-year readmission, frailty (AUC 0.642) was outperformed by both models using ECI (AUC 0.725, p = 0.039) and frailty+ECI (AUC 0.734, p = 0.038).

CONCLUSIONS

These findings suggest that frailty and ECI are useful in predicting key complications, including mortality, nonroutine discharge, readmission, LOS, and higher costs in NF1 patients undergoing intracranial tumor resection. Consideration of a patient’s frailty status is pertinent to guide appropriate inpatient management as well as resource allocation and discharge planning.

Endoscopically Treated Subacute Subdural Hematoma Presenting Postoperative Cerebral Hyperperfusion Syndrome: Chronological Changes of Cerebral Blood Flow on Arterial Spin Labeling and Subcortical Low Intensity on Fluid-attenuated Inversion Recovery Images

Subacute subdural hematoma (SASDH) is a neurotraumatic entity. There are few reports of chronological changes of cerebral blood flow (CBF) on arterial spin labeling (ASL) and subcortical low intensity (SCLI) on fluid-attenuated inversion recovery (FLAIR) images of magnetic resonance imaging (MRI) observations from the injury onset, deterioration, to post-surgery. We reported a SASDH patient presenting postoperative cerebral hyperperfusion (CHP) syndrome with chronological changes of those findings. An 85-year-old woman fell and presented right ASDH. She was treated conservatively due to no neurological deficits. On day 3, ASL image revealed increased CBF against brain compression. On day 7, the CBF was normalized on ASL image, but SCLI was confirmed. On day 14, SCLI was strengthened. Then she developed left hemiparesis due to brain compression by SASDH. Considering age and comorbidities, we performed endoscopic hematoma removal under local anesthesia, and her neurological deficits improved after the surgery. On postoperative day 1, she newly presented left upper limb paresis. MRI revealed increased CBF and enhanced SCLI. We diagnosed CHP syndrome, and antihypertensive treatment improved the symptoms gradually. However, SCLI had been consistently observed, and CBF easily changed depending on the blood pressure, suggesting dysfunction of the CBF autoregulation. We showed the endoscopically treated SASDH patient with CBF’s chronological changes on ASL images and SCLI on FLAIR images. Long-time brain compression would lead to dysfunction of the CBF autoregulation, and we should be careful about CHP syndrome after the endoscopic surgery for SASDH.

Diamond-Shaped Mini-Craniotomy: A New Concept in Neurosurgery

BACKGROUND

 We describe, step by step, a modified, less invasive, diamond-shaped mini-craniotomy that optimizes dural opening and can be performed in elderly patients affected by acute subdural or intracerebral hematomas, in therapy with antiplatelets or anticoagulants.

METHODS

 We retrospectively analyzed the clinical records of 67 patients (mean age of 78.5 years) treated in our institution, during a period of 10 years, with this novel diamond-shaped craniotomy. Seventeen patients were treated for intracerebral hemorrhage and 50 patients for acute subdural hematomas. All the patients were in therapy with antiplatelets or anticoagulants.

RESULTS

 Approach-related complications were not detected. Ten of 67 patients (14.9%) presented temporal muscle atrophy; there was no scar deformity, paresthesia, hyperalgesia, or ramus frontalis palsy around the scalp incision. Thirty-day mortality was 22%. The mean follow-up was 1.3 years. One-month postoperative brain computed tomography scans showed a satisfactory hematoma evacuation in 57 of 67 patients (85%).

CONCLUSIONS

 The diamond-shaped mini-craniotomy for acute subdural and intracerebral hematomas is safe and effective, and it should be considered as an alternative to traditional approaches, particularly in elderly patients.

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases

BACKGROUND

Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time.

OBJECTIVE

To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study.

METHODS

We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018.

RESULTS

The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3).

CONCLUSION

Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature

INTRODUCTION

Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT.

METHODS

A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included.

RESULTS

A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%.

CONCLUSIONS

EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.

Burr-Hole Evacuation of an Acute Epidural Hematoma using the Artemis Neuroevacuation Device With Flexible Endoscopic Visualization: 2-Dimensional Operative Video

Minimally invasive (MIS) endoscopic burr-hole evacuation of both acute and subacute subdural hematomas (SDHs) has been demonstrated as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates.^1,2 Although generally safe and effective, there are risks of complications including SDH recurrence or new hemorrhage including epidural hematoma (EDH).^3,4 Acute intraparenchymal hemorrhage has also been successfully treated using MIS endoscopic techniques with the assistance of aspiration devices; however, acute EDHs generally still necessitate a craniotomy for evacuation, nullifying many of the advantages of burr-hole craniostomy.^5,6 In this surgical video, we demonstrate-to our knowledge-the first case of endoscopic burr-hole evacuation of an acute EDH using an Artemis Neuro Evacuation device (Penumbra, Alameda, CA). We present the case of a 40 year-old man with a left anterior middle cranial fossa arachnoid cyst who developed a traumatic left subacute SDH and hemorrhage into the cyst. He underwent burr-hole craniostomy for endoscopic evacuation of subacute SDH, evacuation of hemorrhage within the cyst, and fenestration of arachnoid cyst. On postoperative day 2, he developed an acute left EDH with midline shift. An Artemis device was inserted into 1 of the pre-existing burr-holes and used to evacuate the acute EDH with direct visualization from a flexible endoscope inserted into the second burr-hole. The patient did well, was discharged 2 days later, and demonstrated complete resolution of hemorrhage 5 weeks post-procedure. The video also provides a brief background on arachnoid cysts, their association with hemorrhage, and MIS techniques for hemorrhage evacuation.^7-12 There is no identifying information in the video. The patient provided informed consent for both procedures (Video 1).

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

Neurocritical Management of Traumatic Acute Subdural Hematomas

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Fifteen Cases of Endoscopic Treatment of Acute Subdural Hematoma with Small Craniotomy under Local Anesthesia: Endoscopic Hematoma Removal Reduces the Intraoperative Bleeding Amount and the Operative Time Compared with Craniotomy in Patients Aged 70 or Older

We report cases of acute subdural hematoma (ASDH) treated by endoscopic hematoma removal with a small craniotomy under local anesthesia. From 2015 to 2019, we retrospectively analyzed 15 ASDH patients who were 70 years or older and met our criteria for endoscopic treatment: (1) comorbidities indicated risks associated with a large craniotomy under general anesthesia; (2) decompressive craniectomy was unlikely; and (3) an enlarging hematoma was absent. We also performed a case-control study using the inverse probability weighting method to compare the 15 patients to 20 ASDH patients who were 70 years or older, met criteria (2) and (3), and were treated by craniotomy between 2012 and 2019. Among the 15 ASDH patients, the median age was 86 (range, 70-101) years, and fall was the common cause. The median Glasgow Coma Scale score on admission, operative time, stay time in the operation room, and bleeding amount were 8 (6-15), 91 (48-156) min, 120 (80-205) min, and 20 (5-400) mL, respectively. The extraction rates of all the hematomas exceeded 90%. No patients required conversion to craniotomy under general anesthesia. Three patients had favorable outcomes, and five died. The comparison with craniotomy revealed that the endoscopic procedure reduced the intraoperative bleeding amount, operative time, and stay time in the operation room (p <0.001, p = 0.02, and p <0.001, respectively). In summary, endoscopic hematoma removal for selected ASDH patients aged 70 years or older did not improve functional outcomes but reduced the bleeding amount and the operative time compared with craniotomy.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.