Endoscopic washout: a new technique for treating chronic subdural hematomas in infants

Chronic hematomas are a common problem during infancy and usually occur as the consequence of trauma. They tend to enlarge and are often managed successfully with repeated subdural taps. In patients with collections that fail to respond to percutaneous drainage, the choice of operative management, including burr hole evacuation, shunting, or craniotomy, remains controversial. A new technique, called endoscopic washout, was successfully used in 7 children under the age of 2 years who presented with irritability, vomiting, seizures, and rapid head growth. Preoperative computerized tomography (CT) scans demonstrated enlarging, bilateral, chronic subdural collections; these failed to respond to repeated percutaneous taps over 10 days. With the patient positioned supine, bilateral linear incisions were made anterior to the coronal suture in the midpupillary lines and burr holes were placed. After the dura and outer membrane were opened and coagulated with bipolar cautery, a 4-mm steerable fiberscope was introduced into the subdural space to visualize the collections, evacuate any residual clot, and continuously irrigate the space with lactated Ringer's solution warmed to physiologic temperature. No bridging vessels or synechiae were violated; nitrous oxide and hyperventilation were discontinued before removing the fiberscope. The subdural space was irrigated again prior to closure. At follow-up (range 18 months to 8 years), CT scans showed reexpansion of the brain and no reaccumulation of the hematomas. We conclude that the endoscopic washout is a safe, uncomplicated treatment for chronic subdural hematomas in infants; is more effective than treatment with conventional burr holes alone, and eliminates the need for shunting or craniotomy.