Endoscopic Surgery for Traumatic Acute Subdural Hematoma
An 87-year-old woman who had undergone coil embolization for a ruptured middle-cerebral artery aneurysm and placement of a ventriculoperitoneal shunt for normal pressure hydrocephalus 5 years earlier fell and hit her head. She suffered consciousness disturbance and was transported to our hospital 6 h after the fall. At the time of admission, she was confused and manifested right hemiplegia. Her Glasgow Coma Scale score was 8 (E2V2M4). A computed tomography (CT) scan showed a thick, (2 cm in diameter) left-frontotemporal ASDH and a marked midline shift (fig. ). Her pupils were isocoric and her light reflex was prompt.\nThe possibility of impending brain herniation required emergency evacuation of the ASDH. As her advanced age and poor condition rendered general anesthesia risky, we opted for endoscopic evacuation under local anesthesia. In case this proved impossible, we simultaneously prepared for performing a craniotomy under general anesthesia. With her head in a neutral position, we made a single burr hole at a site on her left forehead. We then increased the hole to 15 mm in diameter in order to obtain a wide-angle endoscopic field. As the skin incision was along a wrinkle, it raised minimal cosmetic concerns. We introduced a rigid endoscope with a tip angle of 0° (Machida Endoscope Co. Ltd., Tokyo, Japan). After incising the dura, we observed a dark red clot. There was no outer membrane associated with chronic subdural hematoma. After evacuating the clot beneath the burr hole, we used the rigid endoscope to introduce a transparent sheath (10 mm in diameter) into the hematoma cavity. Although a portion of the soft clot was hard, it could be removed easily with a suction tube (fig. ). Irrigation with artificial cerebrospinal fluid (Artcereb®, Otsuka Factory, Tokushima, Japan) yielded a clear operative field and precise manipulation was possible. Upon removing the hematoma, we noted arterial bleeding on the brain surface. We applied a suction tube to the bleeding point (fig. ) and coagulated it electrically (fig. ). After confirming the removal of the hematoma and complete hemostasis, we filled the subdural space with artificial cerebrospinal fluid. The burr hole was covered with a ceramic burr-hole button and the skin incision was sutured cosmetically. The entire procedure was completed in 47 min.\nA postoperative CT scan showed an obvious reduction of the hematoma; there was no brain shift or swelling (fig. ). Her consciousness disturbance and right hemiplegia improved immediately. She was discharged 30 days later without any neurological deficits.