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

  • Technical Note - Neurosurgical Techniques
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Abstract

Background

The first choice to treat acute subdural hematoma (SDH) is a large craniotomy under general anesthesia. However, increasing age or comorbid burden of the patients may render invasive treatment strategy inappropriate. These medically frail patients with SDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive and even available under local anesthesia. Although hematoma evacuation with a rigid endoscope for acute or subacute SDHs has been reported in the literature, use of a flexible endoscope may have distinct advantages. In this article, we attempted to clarify the utility of small craniotomy evacuation with a flexible endoscope for acute and subacute SDH in the elderly patients.

Method

Between November 2013 and September 2016, a total of 17 patients with acute SDH (15 patients), subacute SDH (1 patient), or acute aggravation of chronic SDH (1 patient) underwent hematoma evacuation with a flexible endoscope at our hospital and were enrolled in this retrospective study. Either under local or general anesthesia, the SDH was removed with a flexible suction tube with the aid of the flexible endoscope through the small craniotomy (3 × 4 cm). Hematoma evacuation rate, improvement of clinical symptoms, and procedure-related complications were evaluated.

Results

Hematoma evacuation rate was satisfactory, and statistically significant clinical improvement was observed in postoperative Glasgow Coma Scale in all cases compared to the preoperative assessment. No procedure-related hemorrhagic complications were observed.

Conclusions

The results reported here suggest that small craniotomy evacuation with a flexible endoscope is a safe, effective, and minimally invasive treatment for acute and subacute SDH in selected cases.

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Acknowledgements

We thank Paul Williams (Kurashiki Central Hospital) for his substantial help in the writing of this article.

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Authors and Affiliations

  1. Department of Neurosurgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan

    Toshinari Kawasaki, Yoshitaka Kurosaki, Hitoshi Fukuda, Masanori Kinosada, Ryota Ishibashi, Akira Handa, Masaki Chin & Sen Yamagata

Authors
  1. Toshinari Kawasaki
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  2. Yoshitaka Kurosaki
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  3. Hitoshi Fukuda
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  4. Masanori Kinosada
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  5. Ryota Ishibashi
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  6. Akira Handa
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  7. Masaki Chin
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  8. Sen Yamagata
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Corresponding author

Correspondence to Toshinari Kawasaki.

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Disclosure

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

For this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

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Comments

The authors report on the use of a flexible endoscope for the evacuation of acute and subacute subdural hematomas through a small craniotomy.

Treatment of acute and subacute subdural hematoma in elderly or very sick people is a common problem in neurosurgery and a further increase in frequency is expected at least in the industrialized countries. Outcome is often poor due to medical conditions and invasiveness of the procedure. On the other hand, if the hematoma volume and its mass effect are relevant a conservative approach is almost invariably burdened by bad outcome.

In this scenario, any less invasive technique is welcomed.

This is the first report on the use of a flexible endoscope to treat these patients. The proposed technique seems to provide a good evacuation rate with remarkable clinical results.

The retrospective design and the small series limits the interpretation of the results, even if this aspect is clearly underlined by the authors. Moreover, outcome measures appear honestly reported and justify further application to confirm results. In the reviewer’s opinion, the only main limitation of this technique lays in the difficult maneuverability to obtain good hemostasis. The other claimed limitation “inability of decompression for postoperative brain swelling” has no clinical impact because there is no role for decompressive craniectomy in these very selected group of patients.

The short video provides a very clear demonstration of the surgical technique.

Domenico d’Avella, Padova, Italy.

Filippo Flavio Angileri, Messina, Italy.

Kawasaki and colleagues report their preliminary experiences with the evacuation of acute and subacute subdural hematomas in 17 patients using the assistance of a flexible endoscope. As the authors point out, the use of rigid endoscopes is well-known in the treatment of acute and especially chronic subdural hematomas. However, the use of a flexible endoscope seems to offer some advantages in selected cases. Further evaluation and a prospective, controlled study with larger groups of patients are recommended.

M. Reinges,

Bremen, Germany.

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Kawasaki, T., Kurosaki, Y., Fukuda, H. et al. Flexible endoscopically assisted evacuation of acute and subacute subdural hematoma through a small craniotomy: preliminary results. Acta Neurochir 160, 241–248 (2018). https://doi.org/10.1007/s00701-017-3399-2

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  • DOI: https://doi.org/10.1007/s00701-017-3399-2

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