Technical Note
Endoscopic-assisted evacuation of subdural collections

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Abstract

Treatment of chronic subdural haematoma (SDH) using endoscopic-assisted techniques is a minimally invasive method that may provide an addition to the standard technique of burr-hole craniostomy drainage.

Over a 12-month period the authors used endoscopic assistance with burr-hole craniostomy drainage, and prospectively collected data to review the technique. Ten patients were treated during the study, with an average age of 67. Subsequent to the study, one further procedure was performed on a 79-year-old man.

Although endoscopic assistance did not alter the intra-operative plan in most patients, it did assist with inserting a subdural catheter for washout of the subdural space, assessing for multi-loculation of the SDH and providing visual images that were captured for discussion with the patient/family and for later study. In one patient, endoscopy assisted with the visualisation and destruction of neomembranes.

We conclude that the technique is unlikely to alter the surgeon’s pre-operative or intra-operative plan; however, in selected circumstances, it could make the procedure safer with enhanced intra-operative visualization and may also allow for the identification and destruction of neomembranes or solid clots under direct vision.

Introduction

There are three principal techniques to address chronic subdural haematoma (SDH): (i) twist drill craniostomy, (ii) burr-hole craniostomy, and (iii) craniotomy. They have different profiles for morbidity, mortality, recurrence rate and cure rate.1 Twist drill and burr-hole craniostomy can be considered first tier treatments, whereas craniotomy may be used as a second tier treatment.

The overall post-operative outcome of surgical treatment for chronic SDH has not improved substantially over the past 20 years.2 We conducted the present study to establish technical issues and safety of endoscopic-assisted burr-hole craniostomy prior to a more comprehensive longer-term outcome study. There is little in the literature that explores the use of endoscopy for the evacuation of chronic SDH.

The treatment of loculated chronic SDH using endoscopic-assisted operative techniques is a minimally invasive method and a potential therapeutic addition or alternative to the standard technique. The application of intracranial endoscopy in neurotraumatology was first considered as a technical principle in the 1980s.3 We aimed to investigate the hypothesis that minimally invasive inspection of haematoma cavities is possible and may potentially enhance the therapeutic intervention of burr-hole drainage of chronic subdural collections. Over a 12-month period, we have used endoscopic assistance with single burr-hole drainage, and prospectively collected data to review the technique.

Section snippets

Materials and methods

The indications for burr-hole craniostomy surgery are beyond the scope of this article; however, all 10 of the initial patients in this study had CT scan findings consistent with either a chronic or subacute subdural collection (Table 1). The authors prefer a single burr-hole technique, with the incision and burr-hole over the subdural collection at its maximal depth. All burr-holes were performed with a high-speed drill, with the diameter of the hole ranging from 20 mm to 35 mm. Following

Results

Over 12 months, a total of 10 procedures were attempted with endoscopic assistance. Subsequent to this, 1 further patient was involved in the study. In 2 patients, conditions were not suitable for the introduction of an endoscope due to inadequate working volume. Eight of the 10 procedures were documented with still picture capture. Six procedures were timed with a mean additional time of 22 min due to endoscopic intervention. There was no additional morbidity throughout the study as a result of

Discussion

Chronic SDHs can be treated operatively via twist drill craniostomy, burr-hole craniostomy or craniotomy. There is an abundance of literature advocating which is the best technique yielding the lowest morbidity and mortality given the clinical picture and radiological findings. Burr-hole treatment is generally accepted as being safer than a craniotomy, and the latter should be reserved for such indications as repeated recurrence of the haematoma, solid consistency of the haematoma, lack of

References (15)

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