Endoscopic Management of Chronic Subdural Hematoma

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.

Endoscopic Membranectomy's Role in the Treatment of Nonhomogeneous Chronic Subdural Hematoma (EMiT-CSDH): Prospective Single-arm Interventional Pilot Study

BACKGROUND

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition characterized by blood accumulation within the border cell layer. Despite various treatment options-medical, endovascular, and surgical-recurrence rates remain high. Our pilot study investigates the safety and efficacy of endoscopic membranectomy (EM) in reducing recurrence in nonhomogenous CSDH.

METHODS

This was a prospective single-arm interventional pilot study from March to June 2023. It included patients of all ages who presented with symptomatic nonhomogenous CSDH requiring surgical intervention.

RESULTS

A total of 19 patients were enrolled in this study. The average age was 60.4 ± 10.4 years. The male:female ratio was 5.3:1. In this group, 73.7% (n = 14) of patients had a history of trauma. All patients presented with a history of altered sensorium and contralateral limb weakness. The most common type of CSDH was trabecular (42.1%), followed by gradient (21%), separated (15.8%), and laminar (15.8%). The average duration of surgery was 43.42 ± 10 minutes. CSDH may be thin or thick based on its tractability and has significance in EM technique. All patients started recovering within 24 hours. All patients were asymptomatic, without any neurologic deficit, at 2 weeks, and remained so at the 6-month review. In 17 patients, the 6-month follow-up computed tomography did not show any bleeding/recurrence. There were no postoperative seizures, wound-healing issues, or infections.

CONCLUSIONS

There are multiple treatment options for CSDH at present. EM is a potentially safe and effective treatment for CSDH, with lower recurrence and faster recovery. Large-scale controlled studies on EM are required.

A Model with Feedback Mechanism for Learning Hand-Eye Coordination: A Pilot Study

BACKGROUND

Practicing neuroendoscopic skills like hand-eye coordination is mandatory before embarking on actual surgeries. Synthetic models are able alternatives for cadavers and animals. Presently available models in the literature are either very costly or lack a feedback mechanism, which makes training difficult.

OBJECTIVE

We aimed to make a basic low-cost neuroendoscopic hand-eye coordination model with a feedback mechanism.

METHODS AND MATERIALS

An electronic circuit in series was designed inside a clay utensil to test inadvertent contact of the working instrument with implanted steel pins, which on completion lighted a light-emitting diode (LED) and raised an alarm. Two exercises-moving-a-rubber exercise and passing copper rings of multiple sizes were made and tested by 15 neurosurgeons.

RESULTS

The moving-a-rubber exercise was completed by 6/15 (40%) neurosurgeons in the first attempt, 6/15 (40%) in the second, and 3/15 (20%) in the third attempt. For the 1.5 cm copper ring passing exercise, 12/15 (80%) successfully performed in the first attempt; for 1 cm copper ring, 6/15 (40%) performed in the first; and for the 0.5 cm copper ring, 1/15 (6.6%) performed in the first attempt. The time to finish all the exercises significantly decreased in the third successful attempt compared to the first.

CONCLUSION

The model gave excellent feedback to the trainee and examiner for basic neuroendoscopic hand-eye coordination skills.

Automated Preoperative and Postoperative Volume Estimates Risk of Retreatment in Chronic Subdural Hematoma: A Retrospective, Multicenter Study

BACKGROUND AND OBJECTIVES

Several neurosurgical pathologies, ranging from glioblastoma to hemorrhagic stroke, use volume thresholds to guide treatment decisions. For chronic subdural hematoma (cSDH), with a risk of retreatment of 10%-30%, the relationship between preoperative and postoperative cSDH volume and retreatment is not well understood. We investigated the potential link between preoperative and postoperative cSDH volumes and retreatment.

METHODS

We performed a retrospective chart review of patients operated for unilateral cSDH from 4 level 1 trauma centers, February 2009-August 2021. We used a 3-dimensional deep learning, automated segmentation pipeline to calculate preoperative and postoperative cSDH volumes. To identify volume thresholds, we constructed a receiver operating curve with preoperative and postoperative volumes to predict cSDH retreatment rates and selected the threshold with the highest Youden index. Then, we developed a light gradient boosting machine to predict the risk of cSDH recurrence.

RESULTS

We identified 538 patients with unilateral cSDH, of whom 62 (12%) underwent surgical retreatment within 6 months of the index surgery. cSDH retreatment was associated with higher preoperative (122 vs 103 mL; P < .001) and postoperative (62 vs 35 mL; P < .001) volumes. Patients with >140 mL preoperative volume had nearly triple the risk of cSDH recurrence compared with those below 140 mL, while a postoperative volume >46 mL led to an increased risk for retreatment (22% vs 6%; P < .001). On multivariate modeling, our model had an area under the receiver operating curve of 0.76 (95% CI: 0.60-0.93) for predicting retreatment. The most important features were preoperative and postoperative volume, platelet count, and age.

CONCLUSION

Larger preoperative and postoperative cSDH volumes increase the risk of retreatment. Volume thresholds may allow identification of patients at high risk of cSDH retreatment who would benefit from adjunct treatments. Machine learning algorithm can quickly provide accurate estimates of preoperative and postoperative volumes.

Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

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.

Middle Meningeal Artery Embolization Combined With Endoscopic Treatment for Chronic Subdural Hematoma

OBJECTIVE

To explore the clinical feasibility of middle meningeal artery (MMA) embolization combined with endoscopic treatment for new or recurrent chronic subdural hematoma (CSDH).

METHODS

Twenty patients with CSDH treated in the Binzhou Medical University Hospital from June 2020 to October 2022 were analyzed retrospectively. The clinical information, prognosis, imaging results, and surgical results of the patients were collected and analyzed. The authors first performed MMA embolization, and then endoscopic treatment of CSDH was performed after successful embolization of MMA. Results: All 20 patients with CSDH were successfully treated with MMA embolization combined with endoscope-assisted evacuation. The symptoms of all patients were relieved, no surgical complications occurred, and no rebleeding and recurrence were found in follow-up computed tomography.

CONCLUSION

Middle meningeal artery embolization combined with endoscopic treatment of CSDH has a good clinical effect, and it may prevent postoperative recurrence.

Positioning and design by computed tomography imaging in neuroendoscopic surgery of patients with chronic subdural hematoma

BACKGROUND

Neuroendoscopy is a very useful technique to Chronic Subdural Hematoma (CSH). But how to achieve the goal of treatment more minimally invasive?

AIM

To develop a simple, fast and accurate preoperative planning method in our way for endoscopic surgery of patients with CSH.

METHODS

From June 2018 to May 2020, forty-two patients with CSH, admitted to our hospital, were performed endoscopic minimally invasive surgery; computed tomography (CT) imaging was employed to locate the intracerebral hematoma and select the appropriate endoscopic approach before the endoscopic surgery. The clinical data and treatment efficacy were analyzed.

RESULTS

According to the learning of CT scanning images, the surgeon can accurately design the best minimally invasive neuroendoscopic surgical approach and realize the precise positioning and design of the drilling site of the skull and the size of the bone window, so as to provide the most effective operation space with the smallest bone window. In this group, the average operation time was only about 1 h, and the clearance rate of hematoma was about 95%.

CONCLUSION

Patients with CSH can achieve good therapeutic effect by using our way to positioning and design to assist the operation of CSH according to CT scan and image, and our way is very useful and necessary.

Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis

The purpose of this study was to compare neuroendoscopy-assisted burr-hole evacuation with conventional burr-hole evacuation in the treatment of chronic subdural hematoma (CSDH), and to evaluate the curative effect of neuroendoscopy. This study follows PRISMA guidelines and uses the keywords "chronic subdural hematoma," "neuroendoscopies," "neuroendoscopy," "endoscopy," "endoscopic neurosurgery," and "neuroendoscopic surgery" to conduct an electronic search of online databases, including PubMed, Embase, Web of Science, and Cochrane Library. There were no restrictions on language or publication year. This meta-analysis involved 948 patients in six studies. The results showed that the recurrence rate in the neuroendoscopy group was significantly lower than that in the conventional burr-hole group (3.1% vs. 13.8%, P<0.001). Compared with the control group, the neuroendoscopy group had a longer operation time (P<0.001) and a shorter postoperative drainage time (P<0.001). In addition, there was no significant difference in hospital stay (P=0.14), mortality (P=0.39), postoperative morbidity (P=0.12), or 6-month neurological outcomes (P=0.32) between the two groups. It should be noted that the comparison of neurological outcomes was based on 269 patients (6/106 vs. 14/163). Compared with conventional burr-hole evacuation, neuroendoscopy-assisted burr-hole evacuation reduces the recurrence rate of CSDH and shortens the postoperative drainage time. However, the neuroendoscopy group did not have lower mortality or morbidity or better functional outcomes. In the future, randomized controlled trials are needed to further evaluate the efficacy and safety of neuroendoscopic surgery.

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

BACKGROUND

Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment.

OBJECTIVE

To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH.

METHODS

A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component.

RESULTS

In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments.

CONCLUSION

Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.

The Guidewire-assisted Drainage Catheter Placement in Chronic Subdural Hematoma

Background

Chronic subdural hematoma (cSDH) is a common neurosurgical pathology associated with older age. The burr hole drainage is a predominant technique with a lower incidence of recurrence and morbidity. The blind placement of the subdural drain could result in intracerebral hemorrhage. This paper describes a simple and reliable technique for drainage catheter placement in cSDH to reduce intracerebral hemorrhage.

Methods

Forty-nine consecutive patients with cSDH were treated with The Guidewire-assisted Drainage Catheter Placement Technique between July 2019 and June 2021. Epidemiological, clinical and radiographical data were collected and reviewed. The operative technique consists of an angular guidewire tip and catheter. Under the navigation of the guidewire, the catheter is inserted into the subdural space and the length of catheter remaining in the subdural space was 4–5 cm. The catheter was tunneled subcutaneously and fixed at the point where it emerged from the scalp.

Results

Forty-nine consecutive patients underwent 55 The Guidewire-assisted Drainage Catheter Placement. The gender distribution was 37 men and 12 women. The mean age was 69.3 years. The patients presented with headache (31 patients), weakness of limbs (28 patients), speech disturbances (7 patients), and Altered behavior (6 patients). Neither intracerebral hemorrhages nor post-operative seizure occurred. Forty-seven patients were improved after the operation. The recurrence occurred in one patient.

Conclusions

The Guidewire-assisted Drainage Catheter Placement Technique is a reliable method for the insertion of a subdural catheter to evacuate of the Chronic Subdural Hematoma, and is associated with an extremely low risk to cortical structures and cerebral veins.

Microvascular proliferation in the clots: The key finding of acute subdural hematoma transforming into chronic subdural hematoma?

Background:

Despite extensive investigations, the exact etiology of chronic subdural hematoma (CSDH) remains elusive. Organized CSDHs are a distinct but less-understood type of CSDH.

Case Description:

A 50-year-old hypertensive woman experienced headache without any previous head injury. At presentation, the patient showed no focal neurological deficits. Cranial computed tomography (CT) revealed a slightly compressive subdural hematoma that spontaneously regressed and no intracranial vascular lesions. Cerebral magnetic resonance imaging identified a non-enhancing nodular lesion in the subdural hematoma. After the patient presented disorientation and aphasia on post hospitalization day 14, CT showed a considerable enlargement of the subdural hematoma. Partial removal of the bi-layered hematoma was performed through a parietal craniotomy. Histological examination revealed microvascular proliferation in both the outer membrane and the nodular lesion. On postoperative day 35, CT demonstrated a remarkable resolution of the residual hematoma.

Conclusion:

Development of microvascular proliferation in the clots of an acute subdural hematoma may lead to its rapid enlargement as an organized CSDH. Organized CSDH can be managed by partial removal of the outer membrane and hematoma through a craniotomy.

Derivation of a Clinical Score for Prediction of Recurrence Following Evacuation of Chronic Subdural Hematoma: A Retrospective Cohort Study at a National Referral Centre

BACKGROUND

Chronic subdural hematoma (cSDH) is a common pathology, and recurrence is a common complication, which may be predicted by certain patient and radiologic factors. Empiric radiologic surveillance has been shown to convey no benefit.

METHODS

A retrospective review of a prospectively collated database was performed. Preoperative and postoperative noncontrast computed tomography scans were reviewed. Radiologic appearance, preoperative hematoma volume, patient age, presence of bilateral hematomas, maximal hematoma thickness, and therapeutic coagulopathy were assessed as predictors. Receiver operating characteristic curve analysis, logistic regression, and LASSO regression were used to select potential predictors. A multivariate model was then fitted, and a score was derived.

RESULTS

A total of 142 patients were included. Maximal hematoma thickness >12 mm (P = 0.02) and age >65 years (P = 0.01) were found to correlate with the likelihood of recurrence. Bilateral hematomas and a hyperdense or mixed density appearance were also identified on LASSO regression. Bilateral hematomas (P = 0.19), hyperdense or mixed density (P = 0.66), maximum thickness >12 mm (P = 0.01), and age >65 years (P = 0.02) were included in the multivariate model. A 6-point score was derived. A score of >3 had a sensitivity of 89% (95% confidence interval [CI] 78%-97%) and specificity of 26% (95% CI, 17%-34%) for predicting recurrence, with recurrence significantly more likely in patients with a score of 4-6 versus those with a score of 0-3 (P = 0.02).

CONCLUSIONS

Certain radiologic findings may predict the recurrence of cSDH following evacuation. The score derived may be useful in identifying patients who might benefit from routine postoperative surveillance imaging.

Segmentation of Chronic Subdural Hematomas Using 3D Convolutional Neural Networks

OBJECTIVE

Chronic subdural hematomas (cSDHs) are an increasingly prevalent neurologic disease that often requires surgical intervention to alleviate compression of the brain. Management of cSDHs relies heavily on computed tomography (CT) imaging, and serial imaging is frequently obtained to help direct management. The volume of hematoma provides critical information in guiding therapy and evaluating new methods of management. We set out to develop an automated program to compute the volume of hematoma on CT scans for both pre- and postoperative images.

METHODS

A total of 21,710 images (128 CT scans) were manually segmented and used to train a convolutional neural network to automatically segment cSDHs. We included both pre- and postoperative coronal head CTs from patients undergoing surgical management of cSDHs.

RESULTS

Our best model achieved a DICE score of 0.8351 on the testing dataset, and an average DICE score of 0.806 ± 0.06 on the validation set. This model was trained on the full dataset with reduced volumes, a network depth of 4, and postactivation residual blocks within the context modules of the encoder pathway. Patch trained models did not perform as well and decreasing the network depth from 5 to 4 did not appear to significantly improve performance.

CONCLUSIONS

We successfully trained a convolutional neural network on a dataset of pre- and postoperative head CTs containing cSDH. This tool could assist with automated, accurate measurements for evaluating treatment efficacy.