Yamada Shoko M, Tomita Yusuke, Iwamoto Naotaka, Nishimura Shiori
Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN.
Neurosurgery, Shizuoka Welfare Hospital, Shizuoka, JPN.
Cureus. 2025 Apr 29;17(4):e83213. doi: 10.7759/cureus.83213. eCollection 2025 Apr.
Craniotomy with membranectomy is recommended for advanced organized chronic subdural hematomas (CSDH) that do not resolve with burr-hole irrigation and drainage. Nevertheless, the procedure remains controversial because of its potential complications, which include postoperative acute subdural hematomas and epileptic seizures. At present, for advanced organized CSDH, there is no clear consensus on whether complete membrane removal or incisions are the optimal management. We have obtained good results by performing a small craniotomy and making incisions in the thick, organized inner membrane with a sharp blade, without dissecting the inner membrane. Here, we report a case of organized CSDH that was successfully resolved by the same procedure performed with an endoscope through the burr-hole. An 81-year-old man was referred to our hospital with twice-recurrent CSDH after two burr-hole surgeries, accompanied by persistent left-sided motor weakness. A magnetic resonance imaging revealed an organized inner membrane, so an endoscopic incision of the inner membrane was performed through the previously opened burr-hole. After the clots in the hematoma cavity were cleanly removed, incisions were made randomly in the inner membrane using a sharp blade, with care not to damage the cortex, until pulsation of the brain tissue was observed endoscopically. A follow-up head computed tomography scan on the third postoperative day confirmed brain expansion. The patient recovered completely from the left-sided paralysis and was discharged home on the 20th postoperative day. In an advanced organized CSDH, the brain will not expand without treatment of the inner membrane, and CSDH will invariably recur. Detaching the hard inner membrane is not necessary, and once multiple incisions are made with a scalpel and the brain pulsation is confirmed, expansion can be expected after drainage of the hematoma cavity over multiple days. Several reports of successful treatment for organized CSDH have been reported, but absolute treatment has not yet been established. Incision of the inner membrane in endoscopic burr-hole surgery is a viable treatment option, with the need for large-scale pragmatic studies to prove safety and efficacy.
对于经钻孔冲洗引流无法消退的晚期机化性慢性硬膜下血肿（CSDH），建议行开颅并切除包膜手术。然而，由于该手术存在潜在并发症，包括术后急性硬膜下血肿和癫痫发作，其仍存在争议。目前，对于晚期机化性CSDH，关于完全切除包膜还是切开包膜是最佳治疗方法尚无明确共识。我们通过小骨瓣开颅并用锋利刀片在增厚的机化内膜上切开，而不剥离内膜，取得了良好效果。在此，我们报告1例经钻孔用内镜行相同手术成功治愈的机化性CSDH病例。一名81岁男性在两次钻孔手术后因CSDH复发两次被转诊至我院，伴有持续性左侧肢体运动无力。磁共振成像显示有一层机化内膜，因此通过先前打开的钻孔对内膜进行了内镜下切开。血肿腔内的血凝块被彻底清除后，用锋利刀片在内膜上随机切开，注意不要损伤皮质，直到在内镜下观察到脑组织搏动。术后第3天的头颅计算机断层扫描随访证实脑组织膨起。患者左侧瘫痪完全恢复，术后第20天出院。在晚期机化性CSDH中，如果不处理内膜，脑组织不会膨起，CSDH必然会复发。无需剥离坚硬的内膜，一旦用手术刀进行多处切开并确认有脑搏动，在血肿腔引流数天后可望出现脑组织膨起。已有多篇关于机化性CSDH成功治疗的报道，但尚未确立绝对的治疗方法。内镜下钻孔手术中切开内膜是一种可行的治疗选择，需要大规模的实用性研究来证明其安全性和有效性。
