Abstract
Background/Aim: Subdural hematoma (SDH), a critical brain condition, significantly affects the elderly, making traditional surgeries risky due to their length and potential for blood loss. Endoscope-assisted evacuation offers a safer, less invasive alternative by reducing operation time and minimizing damage, providing an effective solution for older patients. This study evaluated six patients treated with endoscopic evacuation for different stages of SDH from August 2019 to July 2023. Patients and Methods: Selection criteria were based on altered consciousness, lack of severe brain contusion, SDH thickness over 1 cm, or midline shift over 0.5 cm. The technique used a burr hole and rigid lens endoscope for hematoma removal, focusing on shorter surgery times and better outcomes. Results: Patients aged between 63 to 84 years showed no surgical fatalities, with all recovering well by discharge. Hematoma clearance rates were 76.9% at three days, improving to 96.8% after one month. Conclusion: Endoscope-assisted evacuation is a safe, efficient treatment for elderly patients with various stages of SDH, offering a less invasive option with potential for better outcomes. It supports the trend towards minimally invasive neurosurgery, with further research needed to optimize patient selection and understand long-term benefits.
A subdural hematoma (SDH) is a critical condition, which develops in the space between the dura mater and arachnoid membranes leading to increased intracranial pressure (IICP). This condition can also manifest in individuals without a history of significant trauma, including those on anticoagulant therapy, patients with hematologic disorders, or individuals who have undergone hydrocephalus shunt placement. Representing approximately one-third of all severe traumatic brain injuries (TBIs), this life-threatening situation has prompted neurosurgeons and critical care physicians to significantly focus on the advancement of early therapeutic interventions and surgical techniques over the past decades (1-5). This effort is crucial in addressing the immediate and long-term consequences of SDH, underlining its importance in the field of neurosurgery.
In cases of traumatic SDH accompanied by life-threatening IICP, severe brain midline shifting, or anticipated post-operative brain swelling, decompressive craniectomy and craniotomy are widely discussed surgical options in the existing literature (6-9). However, in elderly patients, these procedures, with their prolonged duration of operation and anesthesia, as well as the potential for significant intra-operative blood loss, may increase the risk of morbidity and mortality (10, 11). To mitigate these risks while maintaining the effectiveness of decompression, neurosurgeons have begun to employ endoscope-assisted evacuation techniques. This approach aims to reduce operative time and structural damage, making it a feasible option for elderly patients with acute, subacute and acute-on-chronic SDHs, as suggested by previous case series (11-14).
In this study, we employed an endoscope-assisted technique to reduce the required craniotomy to the size of a burr hole while ensuring optimal visibility of the surgical field. We also reported on the surgical outcomes associated with this approach. Furthermore, through a comprehensive review of existing literature, we aimed to identify the most suitable candidates for this minimally invasive approach, adding another layer of discussion to the current understanding of endoscopic treatment for SDH in elderly patients.
Patients and Methods
Between August 2019 and July 2023, we analyzed six patients who underwent endoscopic evacuation of acute, subacute or acute-on-chronic SDHs. Acute SDHs (ASDHs) were defined as those with onset less than three days prior to intervention. Subacute SDHs (SASDHs) were chronologically defined as an SDH occurring 4 to 20 days after head trauma (1). An acute-on-chronic SDH (ACSDH) refers to a condition where a new hemorrhage occurs on a preexisting hematoma (15). We present the demographic and clinical characteristics of these patients in Table I. The criteria for selecting endoscopic hematoma evacuation included: persistent symptoms or episodes of consciousness alteration, absence of significant brain contusion or intra-parenchymal hematoma, a maximal SDH thickness greater than 1 cm, or midline shift greater than 0.5 cm. Patients with severe brain swelling evident on pre-operative imaging were deemed unsuitable for burr hole evacuation due to safety concerns.
Demographic and clinical characteristics of six patients with acute, subacute and acute-on-chronic subdural hematomas (SDHs). ACSDH: Acute on chronic SDH; SASDH: subacute SDH; ASDH: acute SDH; mRS: modified Rankin Scale; evac: evacuation.
All procedures were conducted under general anesthesia. A burr hole was placed in the frontal-temporal area, slightly posterior to the center of the hematoma, and subsequently enlarged to approximately 2 cm×2 cm to facilitate surgical instrument manipulation. Hematoma evacuation was performed using a 4 mm rigid 0° lens endoscope, with removal of the hematoma achieved through forceps and a metallic malleable suction catheter following dural opening. Active bleeding sites were managed with bipolar electrocautery or the application of a hemostatic matrix such as Floseal. The decision to administer additional fibrinolysis with a thrombolytic agent through a subdural drainage tube was made based on the presence of residual hematoma.
Informed consent was obtained from the families of all patients. This retrospective study received approval from the Institutional Review Board of Taichung Veterans General Hospital, adhering to the ethical standards outlined in document No. CE22334A, and conformed to the guidelines governing human research ethics.
Results
Endoscopic surgery was performed under general anesthesia for all patients. The mean age of the patients was 71.2 years, with a range of 63 to 84 years. The patient group consisted of three males and three females. The SDHs were located on the right side in three patients and on the left side in three patients. The mean preoperative Glasgow Coma Scale (GCS) score and modified Rankin Scale (mRS) score at admission were 11.5 and 2.5, respectively. The mean hematoma evacuation rate three days postoperatively and one month postoperatively was 76.9% and 96.8%, respectively. The mean operation time ranged from 120 to 210 min, with an average of 155.5 min. There was no surgery-related mortality. At discharge, six patients (100%) experienced a good recovery, with a mRS Score of 0 to 2.
Illustrative cases. Case 2. Subacute SDH. This 79-year-old woman has a history of well-controlled hypertension. She presented with headache and vomiting after a fall at home and was initially admitted to the local medical department for observation. Due to relative weakness in her left lower limb, she was transferred to our hospital. Upon evaluation, her level of consciousness was E4V5M6 on the GCS, and a brain computed tomography (CT) scan revealed a right SASDH with a midline shift. The SASDH was more than 1 cm thick (Figure 1A). Consequently, endoscopic evacuation of the hematoma was arranged. A small craniotomy with a diameter of 2 cm and a dural incision were made, allowing for the evacuation of the SDH located just below and around the craniotomy site. An external ventricular drain (EVD) tube as subdural drainage was inserted into the subdural space to evacuate the remaining hematoma (Figure 2).
Pre-operative and post-operative follow up brain CT images. (A) Initial brain CT scan showing a right subacute subdural hematoma (SASDH) with midline shift. (B) CT scan obtained three days after endoscopic surgery showing subtotal evacuation of the SASDH. (C) One month after endoscopic surgery, a brain CT scan shows no recurrence.
Patient positioning and intra-operative photographs. (A) Illustrative diagram showing a 3.5 cm surgical incision line (indicated by a blue line) over the frontal-temporal area. (B) A small craniotomy with a 2-cm diameter was performed. (C) An external ventricular drain tube was inserted into the subdural space to evacuate the remaining subdural hematoma.
Postoperative CT scans showed that the hematoma was almost completely removed (Figure 1B and C). After the surgery, the muscle power in all four limbs improved to 4 out of 5. By postoperative day 22, the patient’s mRS score had improved to 1, and she was able to return to her normal activities of daily living.
Case 6. Acute-on-chronic SDH. A 71-year-old female presented to our hospital with acute onset of chest tightness. Electrocardiogram revealed inferior wall ST-elevation myocardial infarction. Emergent percutaneous coronary intervention was performed. Post-myocardial infarction echocardiography showed left ventricular ejection fraction 52% with severe mitral valve regurgitation. Therefore, coronary artery bypass grafting with mitral valve repair was performed. Anticoagulant agents with warfarin and enoxaparin were prescribed after surgery. However, aphasia and left hemiparesis were found after using anticoagulant agents for five days. The patient’s level of consciousness was E3V1M6 on the GCS. Brain CT revealed a right frontal-temporal-parietal ACSDH. The ACSDH was more than 1-cm thick (Figure 3A). Evacuation of the hematoma via endoscope was performed. The active bleeding site was identified with the assistance of an endoscope, and hemostasis was achieved (Figure 4A and B). The postoperative CT scan demonstrated subtotal hematoma removal (Figure 3B and C). After surgery, the patient became alert, and the aphasia and left hemiparesis were improved. Given the patient’s cardiac condition, the duration of hospitalization was extended beyond that typical for similar cases.
Pre-operative and post-operative follow up brain CT images. (A) Brain CT scan revealing a right frontal-temporal-parietal acute-on-chronic subdural hematoma (ACSDH). (B) CT scan taken three days postoperatively after endoscopic surgery, showing subtotal evacuation of the ACSDH. (C) One month post-endoscopic surgery, the CT scan reveals no signs of recurrence.
Endoscopic views during operation. (A) The bleeding point was identified with the assistance of an endoscope, and hemostasis was achieved using either bipolar electrocautery or the application of a hemostatic matrix. (B) After hemostasis was complete, warm water was slowly infused until it became clear, as shown in the figure.
Discussion
Currently, craniotomy and decompressive craniectomy remain the predominant treatments for ASDHs. While it is indisputable that patients experiencing ongoing or anticipated severe brain edema require emergent decompressive craniectomy as a lifesaving measure, this approach is often associated with longer operative times, increased blood loss, extended recovery periods, and longer hospital stays, potentially leading to a higher rate of complications or mortality during hospitalization (16-18). Consequently, for patients exhibiting minor brain edema or those elderly with atrophic cerebral parenchyma, burr hole evacuation presents a viable and simpler alternative. Moreover, this less invasive surgical technique offers a beneficial option for patients in poor clinical condition, helping to mitigate the risk of complications under certain circumstances. The same rationale can also be applied to SASDH and ACSDH.
In choosing the optimal site for the burr hole, prevailing literature predominantly advocates for placement just above the hematoma’s center, aiming to minimize the distance to the hematoma for easier access (11, 14). However, based on our experience, positioning the burr hole slightly towards the parietal and occipital regions, rather than directly over the hematoma’s center, facilitates a smoother evacuation process and enhances intraoperative visualization when using an endoscope. This approach is particularly advantageous when the patient’s head is elevated and tilted towards the contralateral side. Furthermore, it helps avoid the obstruction caused by the sphenoid ridge, which can impede hematoma evacuation.
When determining suitability for this technique, elderly patients are often considered prime candidates due to the natural brain atrophy associated with aging, which can accommodate a greater degree of brain swelling compared to younger individuals. Additionally, this demographic frequently presents with comorbidities, making them less able to withstand the rigors of prolonged surgical procedures and significant blood loss (11, 14, 19). Nonetheless, despite the minimally invasive and time-efficient nature of this evacuation surgery, it remains contraindicated for patients with thrombocytopenia or severe coagulopathy, as these conditions pose substantial challenges to achieving effective hemostasis.
The role of thrombolytic agents, such as urokinase or recombinant tissue-type plasminogen activator (rtPA), remained controversial owing to the possibility of hemorrhage progression and other drug adverse events. Mould et al. (20) demonstrated faster improvement with the use of rtPA, which reduces hematoma lysis and edema around the hematoma. From the retrospective study conducted by Ryu et al. (21), minimally invasive aspiration surgery followed by fibrinolytic treatment showed feasible outcome without secondary hemorrhagic events. Unlike stereotactic aspiration of intracerebral hematoma or drainage surgery for chronic SDHs (22-26), there are only sparce literature exploring the utilization of thrombolytic agents in ASDHs, SASDHs, and ACSDHs. More trials are needed to define timing and dosing for thrombolytic agents in these conditions.
Study limitations. Firstly, the sample size was relatively small, with only six patients included in the analysis. Secondly, the use of thrombolytic agents through a subdural catheter was not evaluated in our cohort, as all six patients demonstrated significant reductions in hematoma size on post-operative CT scans. Consequently, this study does not address the potential benefits or feasibility of employing thrombolytics in the management of subdural hematomas.
Conclusion
In summary, our research highlights the safety and time-efficiency of endoscope-assisted evacuation for ASDHs, SASDHs, and ACSDHs in selected patients, presenting it as a less invasive and promising alternative to traditional surgical methods. This approach not only offers potential for improved patient outcomes but also encourages a shift towards minimally invasive techniques in managing suitable cases of ASDHs, SASDHs, and ACSDHs. Future studies should further explore patient selection criteria and long-term impacts to enhance care for this vulnerable population.
Acknowledgements
All data were extracted from Taichung Veterans General Hospital. Neither the patients nor the public were involved.
Footnotes
Authors’ Contributions
Conceptualization, M.-C.H.; methodology, C.-R.L.; validation, C.-C.S. and J.-R.L.; formal analysis, Y.-Y.F.; writing—original draft preparation, M.-C.H.; writing—review and editing, C.-R.L. and C.-Y.L.; supervision, C.-Y.L.; All Authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The Authors declare no conflict of interest in relation to this study. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
- Received July 8, 2024.
- Revision received July 22, 2024.
- Accepted July 23, 2024.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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