Endoscope-Assisted Evacuation of Nonacute Subdural Hematoma: A Technical Case Series and Systematic Review

Chronic subdural hematoma or nonacute subdural hematoma (NASH) remains a common neurosurgical disease, with an incidence of 1.7-20.6:100,000 individuals. Surgical evacuation of chronic subdural hematoma can be complicated by inadequate drainage and recurrence rates up to 20%-30% in some series. We examine the safety and efficacy of endoscope-assisted NASH evacuation and review the literature on the technique.

A consecutive, single-center series of endoscope-assisted NASH evacuations was reviewed to assess patient factors, imaging, and recurrence. A systematic literature review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

A total of 9 patients who underwent endoscope-assisted NASH evacuation were included. This technique showed some improved evacuation of hematoma, removal of membranes, coagulation of at-risk blood vessels, directed placement of surgical drains, visualization of embolization efficacy, coagulation of friable membranes, and removal of acute clot. Only 1 episode of NASH recurrence (11.1%) was seen at the last follow-up. A systematic review of 14 studies with 1353 patients identified the use of membranectomy in 57% of cases and a recurrence rate of 0%-8.8%.

Endoscopic visualization can be a useful adjunct in the modern treatment of NASH. Reduced risk of recurrence was seen compared with those of historical surgical drainage methods including burr holes (20-30%). The inclusion of endoscopic visualization in the modern era with middle meningeal artery embolization may potentially combine methods that can dramatically reduce the recurrence of NASH.