Chronic Subdural Haematoma Treatment with a Rigid Endoscope

Abstract

Surgical treatment is the method of choice in cases of chronic subdural haematoma - as a rule: trephination, drainage with lavage, or repeated drainage (drain reinsertion where the haematoma has been evacuated insufficiently). A poorly manageable but non-negligible group is made up of patients (about 5 - 12 % of all cases) where the less invasive methods of choice keep failing. The equally mini-invasive endoscopic technique appears to be one of the suitable therapeutical approaches before resorting to open-surgery revision. The adapted technique of rigid endoscope insertion permitting sufficient revision and treatment of the subdural space concerned is presented. The method is demonstrated on three case reports where routine trephination with lavage, drainage and repeated drain insertion failed. A very good improvement in clinical condition and graphic findings was achieved in two patients. In the remaining one, the neurological lesion improved ad integrum despite a tiny residual haematoma as visualized by CT. Two weeks later, a clinical relapse had developed and the patient was treated with new trephination and drain reinsertion. The technical aspects of the modification of the endoscopic technique are discussed: stressing the advantages or low-degree invasiveness, scope for keeping intact the inner membrane of the haematoma and avoiding direct invasion of the cerebral tissue. The limits of the method are discussed as well. The authors regard this method as a useful addition to the surgical armamentarium, especially in cases of chronic subdural haematomas resisting conventional approaches.

Key words

Chronic subdural haematoma - trephination - rigid endoscope

References

• 1 McKissock W, Richardson A, Bloom W H. Subdural hematoma. A review of 389 cases.  Lancet. 1960;  1 1365-1369
• 2 Häckel M, Beneš Jr V. Diagnosis and treatment of chronic subdural hematoma (in Czech).  Rozhl Chir. 1993;  3/72 118-123
• 3 Hashimoto N, Sabakibara R, Yamamoto K, Fujimoto M, Yamaki T. Two fluid-blood density levels in chronic subdural hematoma.  J Neurosurg. 1992;  77 310-311
• 4 Rodziewicz G S, Chuang W C. Endoscopic removal of organized chronic subdural hematoma.  Surg Neurol. 1995;  43 569-572
• 5 Shiomi N, Hashimoto N, Takeuchi H, Yamanaka T, Nakagawa N, Mineura K. Endoscopic findings in chronic subdural hematoma.  No Shinkei Geka. 2002;  30 717-722
• 6 Drapkin A J. Endoscopy for chronic SDH.  Surg Neurol. 1997;  48 427
• 7 Gruber D P, Crone K R. Endoscopic washout: A new technique for the treatment of chronic subdural hematoma in infants.  Pediatr Neurosurg. 1997;  27 292
• 8 Hellwig D, Riegel T. Endoscopic evacuation of intracerebral hematomas and septated chronic subdural hematomas. In: Jimenez DF (ed). Intracranial Endoscopic Neurosurgery. 1998: 185
• 9 Hellwig D, Kun T, Bauer Bl, List-Hellwig E. Endoscopic treatment of septated chronic subdural hematoma.  Surg Neurol. 1996;  45 272
• 10 Suzuki J, Takaku A. Nonsurgical treatment of chronic subdural hematoma.  J Neurosurg. 1970;  33 548-553
• 11 Hellwig D, Heinze S, Riegel T, Benes L. Neuroendoscopic treatment of loculated chronic subdural hematoma.  Neurosurg Clin North Am. 2000;  11 525-534
• 12 Häckel M, Masopust V, Kramář F. Chronic subdural haematoma. Development of the treatment methods. ČNCHS Working Days, Plzeň, CR 1999. Prog Abs 22 1999