Technical Note
63
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique to Treat Traumatic Subacute Subdural Hematomas Tetsuya Ueba1
Munenori Yasuda1
Tooru Inoue1
1 Department of Neurosurgery, Fukuoka University School of
Medicine, Fukuoka, Japan
Address for correspondence Tetsuya Ueba, MD, PhD, Department of Neurosurgery, Fukuoka University School of Medicine, Fukuoka, Japan (e-mail: [email protected]).
Abstract
Keywords
► subacute subdural hematoma ► endoscope ► curettage and suction technique ► minimally invasive neurosurgery
Background Traumatic subacute subdural hematomas can usually be evacuated via craniotomy under general anesthesia. We report a traumatic subacute subdural hematoma in an elderly patient that was evacuated by endoscopic burr hole surgery using a curettage and suction technique under local anesthesia. This minimally invasive neurosurgery may lower the morbidity rate in elderly or sick patients with serious cardiac and/or pulmonary lesions in whom the inherent risks of general anesthesia are high. Patient An 88-year-old man was referred to our institution with left hemiparesis 6 days after sustaining a head injury. He was on antiplatelet drugs for severe coronary and peripheral artery disease and underwent hemodialysis three times a week. Results Endoscopic burr hole surgery using a curettage and suction technique resulted in the complete evacuation of his subacute subdural hematoma and complete hemostasis, and he recovered completely. Conclusion Endoscopic burr hole surgery using a curettage and suction technique is a minimally invasive treatment to address subacute subdural hematomas. This method may be particularly useful in older patients in whom general anesthesia poses additional risks.
Introduction Traumatic subacute subdural hematomas are usually evacuated by means of a craniotomy under general anesthesia because they tend to be solid and rigid. However, general anesthesia carries risks for elderly or sick patients with serious cardiac or pulmonary comorbidities. In addition, patients with subdural hematomas are often taking antiplatelet or anticoagulant drugs; therefore the potential for perioperative blood loss and hemorrhage-related sequelae should be minimized by using less invasive approaches.1 We present the case of an elderly patient whose traumatic subacute subdural hematoma was treated successfully by endoscopic burr hole surgery using a curettage and suction
received February 22, 2012 accepted after revision June 28, 2013 published online October 12, 2014
(ECS) technique. To our knowledge, this is the first description of the use of this technique to treat traumatic subacute subdural hematoma.
Case Report An 88-year-old man was referred to our institution with left hemiparesis 6 days after sustaining a head injury. He was taking antiplatelet drugs for severe coronary and peripheral artery disease, and underwent hemodialysis three times a week. Physical examination confirmed grade 4–5 hemiparesis and dysarthria. A computed tomography (CT) scan revealed a subacute subdural hematoma with a volume of
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1358606. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
J Neurol Surg A 2015;76:63–65.
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique
Ueba et al.
Fig. 1 Pre- and postoperative computed tomography (CT) scans. (A) Preoperative CT scan showed deviation of the lateral ventricle and midline by a massive high-density subdural hematoma. The black lines between the putative burr hole edge and the distal edges of the hematoma are shown not to be in contact with the brain surface. (B) Postoperative CT scan showed complete evacuation of the subdural hematoma.
70 mL (►Fig. 1A). He underwent single burr hole craniostomy to evacuate high-density clots using the ECS technique under local anesthesia with conscious sedation. Postoperative CT showed evacuation of the hematoma and complete hemostasis (►Fig. 1B). His neurologic recovery was rapid. On the first postoperative day (POD 1), the paresis and dysarthria had improved sufficiently for him to sit up in bed, and acute phase rehabilitation was started. By POD 2 he could take food by mouth. On POD 7 he was able to walk with assistance. On POD 14 he was transferred to another hospital for further rehabilitation; he scored 2 on the modified Rankin scale.
and conscious sedation. However, the former technique involves 48 hours of continuous drainage, and patients treated with the latter method must undergo drainage for 14 days.
Methods and Results Under local anesthesia, a single burr hole craniostomy was established on the superior temporal line just behind the anterior branch of the superior temporal artery, which was the putative center of the hematoma. An assistant manipulated the endoscope (Olympus Co. Ltd., Tokyo, Japan) at a 30degree angle. A ring curette, generally used in pituitary adenoma surgery, and a detachable suction cannula were used (►Fig. 2A). The flexible curette and suction cannula were bent to fit to the concavity of the skull. The subdural hematoma was located 7 cm into the frontal and temporal, and 5 cm into the parietal and occipital region from the burr hole. Endoscopic examination revealed the bleeding site to be the pial artery on the marginal gyrus, which was coagulated with the suction cannula using a monopolar coagulator (►Fig. 2B). With this technique we accomplished complete evacuation of the hematoma and complete hemostasis.
Discussion Symptomatic subacute subdural hematomas are usually treated via craniotomy under general anesthesia. Two less invasive techniques that require a single burr hole have been reported: the subdural evacuating port2–4 and the simple external drainage method.5 These procedures are quick and simple, and they can be performed under local anesthesia Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
Fig. 2 Evacuation of the subdural hematoma via a burr hole using a curettage and suction technique, and endoscopic exposure of the bleeding point on the pial artery. (A) The subacute subdural hematoma was rigid and could not be removed by suction. There was no evidence of residual hematoma in the hematoma cavity. The suction cannula (asterisk) and the curved curette are shown (number sign). (B) The laceration in the wall of the pial artery was visualized as a pinhole (asterisk).
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
64
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique
65
technique, it is possible to obtain complete hematoma evacuation and complete hemostasis. However, the ECS technique is not suitable for patients who present with acute and/or subacute hematomas and cerebral contusion because of the limited amount of space in which to operate. These patients may require additional external decompression.
References 1 Jeffree RL, Gordon DH, Sivasubramaniam R, Chapman A. Warfarin
2
3
4
5
related intracranial haemorrhage: a case-controlled study of anticoagulation monitoring prior to spontaneous subdural or intracerebral haemorrhage. J Clin Neurosci 2009;16(7):882–885 Asfora WT, Schwebach L. A modified technique to treat chronic and subacute subdural hematoma: technical note. Surg Neurol 2003;59(4):329–332; discussion 332 Lollis SS, Wolak ML, Mamourian AC. Imaging characteristics of the subdural evacuating port system, a new bedside therapy for subacute/chronic subdural hematoma. AJNR Am J Neuroradiol 2006;27(1):74–75 Kenning TJ, Dalfino JC, German JW, Drazin D, Adamo MA. Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. J Neurosurg 2010; 113(5):1004–1010 Endo H, Fukawa O, Mashiyama S, Kawase M. Single burr hole surgery for acute spontaneous subdural hematoma in the aged: patient reports of three cases [in Japanese]. No Shinkei Geka 2004; 32(3):271–276
Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Subacute subdural hematomas can be classified as liquified and suctionable, soft and suctionable, or rigid and unsuctionable. Subdural hematomas that appear to be of high density on CT scans tend to be rigid and unsuctionable. Rigid unsuctionable hematomas require the placement of a drainage system; they cannot be evacuated completely via the burr hole even after prolonged irrigation. The ECS technique appears to be a promising approach because it facilitates complete evacuation of rigid unsuctionable hematomas and requires no drainage, can be performed under local anesthesia, clinical management is simple, and rehabilitation can be started promptly. Endoscopic visualization of the hematoma cavity facilitates hemostasis. In our case, the pial artery on the marginal gyrus was identified as the bleeding site using the endoscope. To accomplish complete hemostasis, the instrument must fit the concavity of the skull to allow point suction and coagulation (►Fig. 2). When using the ECS technique, correct placement of the burr hole is essential to permit safe and effective access to evacuate the hematoma. In this case a single burr hole was established at the putative center of the hematoma, but if the hematoma was large an option would be to use two. The ECS technique described here is a useful means of addressing subdural hematomas in elderly and frail patients who might not tolerate the physiologic stress of craniotomy under general anesthesia. With this minimally invasive
Ueba et al.
Copyright of Journal of Neurological Surgery. Part A. Central European Neurosurgery is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
63
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique to Treat Traumatic Subacute Subdural Hematomas Tetsuya Ueba1
Munenori Yasuda1
Tooru Inoue1
1 Department of Neurosurgery, Fukuoka University School of
Medicine, Fukuoka, Japan
Address for correspondence Tetsuya Ueba, MD, PhD, Department of Neurosurgery, Fukuoka University School of Medicine, Fukuoka, Japan (e-mail: [email protected]).
Abstract
Keywords
► subacute subdural hematoma ► endoscope ► curettage and suction technique ► minimally invasive neurosurgery
Background Traumatic subacute subdural hematomas can usually be evacuated via craniotomy under general anesthesia. We report a traumatic subacute subdural hematoma in an elderly patient that was evacuated by endoscopic burr hole surgery using a curettage and suction technique under local anesthesia. This minimally invasive neurosurgery may lower the morbidity rate in elderly or sick patients with serious cardiac and/or pulmonary lesions in whom the inherent risks of general anesthesia are high. Patient An 88-year-old man was referred to our institution with left hemiparesis 6 days after sustaining a head injury. He was on antiplatelet drugs for severe coronary and peripheral artery disease and underwent hemodialysis three times a week. Results Endoscopic burr hole surgery using a curettage and suction technique resulted in the complete evacuation of his subacute subdural hematoma and complete hemostasis, and he recovered completely. Conclusion Endoscopic burr hole surgery using a curettage and suction technique is a minimally invasive treatment to address subacute subdural hematomas. This method may be particularly useful in older patients in whom general anesthesia poses additional risks.
Introduction Traumatic subacute subdural hematomas are usually evacuated by means of a craniotomy under general anesthesia because they tend to be solid and rigid. However, general anesthesia carries risks for elderly or sick patients with serious cardiac or pulmonary comorbidities. In addition, patients with subdural hematomas are often taking antiplatelet or anticoagulant drugs; therefore the potential for perioperative blood loss and hemorrhage-related sequelae should be minimized by using less invasive approaches.1 We present the case of an elderly patient whose traumatic subacute subdural hematoma was treated successfully by endoscopic burr hole surgery using a curettage and suction
received February 22, 2012 accepted after revision June 28, 2013 published online October 12, 2014
(ECS) technique. To our knowledge, this is the first description of the use of this technique to treat traumatic subacute subdural hematoma.
Case Report An 88-year-old man was referred to our institution with left hemiparesis 6 days after sustaining a head injury. He was taking antiplatelet drugs for severe coronary and peripheral artery disease, and underwent hemodialysis three times a week. Physical examination confirmed grade 4–5 hemiparesis and dysarthria. A computed tomography (CT) scan revealed a subacute subdural hematoma with a volume of
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1358606. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
J Neurol Surg A 2015;76:63–65.
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique
Ueba et al.
Fig. 1 Pre- and postoperative computed tomography (CT) scans. (A) Preoperative CT scan showed deviation of the lateral ventricle and midline by a massive high-density subdural hematoma. The black lines between the putative burr hole edge and the distal edges of the hematoma are shown not to be in contact with the brain surface. (B) Postoperative CT scan showed complete evacuation of the subdural hematoma.
70 mL (►Fig. 1A). He underwent single burr hole craniostomy to evacuate high-density clots using the ECS technique under local anesthesia with conscious sedation. Postoperative CT showed evacuation of the hematoma and complete hemostasis (►Fig. 1B). His neurologic recovery was rapid. On the first postoperative day (POD 1), the paresis and dysarthria had improved sufficiently for him to sit up in bed, and acute phase rehabilitation was started. By POD 2 he could take food by mouth. On POD 7 he was able to walk with assistance. On POD 14 he was transferred to another hospital for further rehabilitation; he scored 2 on the modified Rankin scale.
and conscious sedation. However, the former technique involves 48 hours of continuous drainage, and patients treated with the latter method must undergo drainage for 14 days.
Methods and Results Under local anesthesia, a single burr hole craniostomy was established on the superior temporal line just behind the anterior branch of the superior temporal artery, which was the putative center of the hematoma. An assistant manipulated the endoscope (Olympus Co. Ltd., Tokyo, Japan) at a 30degree angle. A ring curette, generally used in pituitary adenoma surgery, and a detachable suction cannula were used (►Fig. 2A). The flexible curette and suction cannula were bent to fit to the concavity of the skull. The subdural hematoma was located 7 cm into the frontal and temporal, and 5 cm into the parietal and occipital region from the burr hole. Endoscopic examination revealed the bleeding site to be the pial artery on the marginal gyrus, which was coagulated with the suction cannula using a monopolar coagulator (►Fig. 2B). With this technique we accomplished complete evacuation of the hematoma and complete hemostasis.
Discussion Symptomatic subacute subdural hematomas are usually treated via craniotomy under general anesthesia. Two less invasive techniques that require a single burr hole have been reported: the subdural evacuating port2–4 and the simple external drainage method.5 These procedures are quick and simple, and they can be performed under local anesthesia Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
Fig. 2 Evacuation of the subdural hematoma via a burr hole using a curettage and suction technique, and endoscopic exposure of the bleeding point on the pial artery. (A) The subacute subdural hematoma was rigid and could not be removed by suction. There was no evidence of residual hematoma in the hematoma cavity. The suction cannula (asterisk) and the curved curette are shown (number sign). (B) The laceration in the wall of the pial artery was visualized as a pinhole (asterisk).
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
64
Endoscopic Burr Hole Surgery with a Curettage and Suction Technique
65
technique, it is possible to obtain complete hematoma evacuation and complete hemostasis. However, the ECS technique is not suitable for patients who present with acute and/or subacute hematomas and cerebral contusion because of the limited amount of space in which to operate. These patients may require additional external decompression.
References 1 Jeffree RL, Gordon DH, Sivasubramaniam R, Chapman A. Warfarin
2
3
4
5
related intracranial haemorrhage: a case-controlled study of anticoagulation monitoring prior to spontaneous subdural or intracerebral haemorrhage. J Clin Neurosci 2009;16(7):882–885 Asfora WT, Schwebach L. A modified technique to treat chronic and subacute subdural hematoma: technical note. Surg Neurol 2003;59(4):329–332; discussion 332 Lollis SS, Wolak ML, Mamourian AC. Imaging characteristics of the subdural evacuating port system, a new bedside therapy for subacute/chronic subdural hematoma. AJNR Am J Neuroradiol 2006;27(1):74–75 Kenning TJ, Dalfino JC, German JW, Drazin D, Adamo MA. Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. J Neurosurg 2010; 113(5):1004–1010 Endo H, Fukawa O, Mashiyama S, Kawase M. Single burr hole surgery for acute spontaneous subdural hematoma in the aged: patient reports of three cases [in Japanese]. No Shinkei Geka 2004; 32(3):271–276
Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Subacute subdural hematomas can be classified as liquified and suctionable, soft and suctionable, or rigid and unsuctionable. Subdural hematomas that appear to be of high density on CT scans tend to be rigid and unsuctionable. Rigid unsuctionable hematomas require the placement of a drainage system; they cannot be evacuated completely via the burr hole even after prolonged irrigation. The ECS technique appears to be a promising approach because it facilitates complete evacuation of rigid unsuctionable hematomas and requires no drainage, can be performed under local anesthesia, clinical management is simple, and rehabilitation can be started promptly. Endoscopic visualization of the hematoma cavity facilitates hemostasis. In our case, the pial artery on the marginal gyrus was identified as the bleeding site using the endoscope. To accomplish complete hemostasis, the instrument must fit the concavity of the skull to allow point suction and coagulation (►Fig. 2). When using the ECS technique, correct placement of the burr hole is essential to permit safe and effective access to evacuate the hematoma. In this case a single burr hole was established at the putative center of the hematoma, but if the hematoma was large an option would be to use two. The ECS technique described here is a useful means of addressing subdural hematomas in elderly and frail patients who might not tolerate the physiologic stress of craniotomy under general anesthesia. With this minimally invasive
Ueba et al.
Copyright of Journal of Neurological Surgery. Part A. Central European Neurosurgery is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
