Shahid Adnan Hussain, Khaleghi Mehdi, Suggala Sudhir, Dyess Garrett, Basett Maxon, Butler Danner Warren, Barnett Asa, Hummel Ursula, Chason Danielle, Thakur Jai Deep
Department of Neurosurgery, University of South Alabama, Mobile, Alabama, United States.
Surg Neurol Int. 2025 May 30;16:214. doi: 10.25259/SNI_340_2025. eCollection 2025.
Multi-septated chronic subdural hematoma (mCSDH) is a special type of chronic subdural hematoma (CSDH) that is characterized by a hematoma cavity separated by fibrous septa that hinders adequate drainage. Treatment of mCSDH using minimally invasive endoscopic-assisted techniques that may serve as an addition to the standard technique of burr-hole craniotomy drainage. No prior video on the nuances of endoscopic membranectomy (EM) has been described.
In this surgical video, we present the case of an 82-year-old female who presented with symptoms of right-sided body weakness and progressive headaches following a ground-level fall a month prior. Computed tomography (CT) head imaging revealed a subacute CSDH overlying the left frontotemporal and parietal regions, measuring 2.4 cm in maximum diameter, with a 0.9 cm midline shift toward the right side and multiple internal septations. Middle meningeal artery embolization could not be performed due to vascular access limitations. The patient consented to the procedure, and a mini left frontoparietal craniotomy was performed with traditional evacuation of the hematoma. Further, a rigid short endoscope (Karl Storz) with a 0° and 30° high-definition lens was introduced into the subdural space. EM and meticulous septation lysis were performed by microscissors and endoscopic bipolar coagulation along with intermittent irrigation, allowing for the maximal drainage of the subdural hematoma (SDH), hemostasis of friable and bleeding membranes with membranectomy, thereby promoting brain expansion. The duration of surgery was 3.7 h. The patient showed immediate improvement in the postoperative period and was discharged home on postoperative day 3. The interval CT scan at 6 months showed no recurrence. IRB approval was not required per the institutional policy.
This video case presentation highlights that EM enhances intra-operative visualization, identification, and division of neo membranes or solid clots under direct vision, helping to prevent recurrence and rebleeding. Judicious use of diluted peroxide, bipolar coagulation, SURGIFLO, and fibrin glue effectively controls bleeding. A rigid 30° endoscope aids in visualizing blind spots and bridging vein attachments, ensuring complete SDH evacuation. By adapting techniques over time, we have improved both patient outcomes by minimizing bleeding and operational effectiveness from aggressively peeling membranes off the dura, which could trigger bleeding, to focusing on lysis of unstable, hemorrhagic membranes while preserving thinner, non-bleeding ones. For distant membranous bleeds, SURGIFLO and fibrin glue are sufficient, and aggressive lysis in the para-sagittal and parieto-occipital posterior areas is avoided.
多分隔慢性硬膜下血肿（mCSDH）是慢性硬膜下血肿（CSDH）的一种特殊类型，其特征是血肿腔被纤维间隔分隔，阻碍了充分引流。使用微创内镜辅助技术治疗mCSDH可作为标准钻孔开颅引流技术的补充。此前尚未有关于内镜下膜切除术（EM）细微差别方面的视频描述。
在此手术视频中，我们展示了一名82岁女性的病例，该患者在一个月前平地摔倒后出现右侧身体无力和进行性头痛症状。头颅计算机断层扫描（CT）成像显示左额颞顶区域上方有亚急性CSDH，最大直径2.4厘米，中线向右侧偏移0.9厘米，并有多个内部间隔。由于血管通路限制，无法进行脑膜中动脉栓塞。患者同意接受该手术，遂行左侧额顶小骨瓣开颅术并传统方式清除血肿。此外，将带有0°和30°高清镜头的硬质短内镜（卡尔史托斯）置入硬膜下腔。通过显微剪刀和内镜双极电凝并辅以间歇性冲洗进行EM及细致的间隔溶解，以实现硬膜下血肿（SDH）的最大程度引流，通过膜切除术对脆弱和出血的膜进行止血，从而促进脑膨出。手术时长为3.7小时。患者术后即刻症状改善，并于术后第3天出院。6个月后的间隔CT扫描显示无复发。根据机构政策，无需获得机构审查委员会（IRB）批准。
本视频病例展示突出表明，EM可增强术中直视下对新形成的膜或固体凝块的可视化、识别及分离，有助于预防复发和再出血。明智地使用稀释过的过氧化氢、双极电凝、SURGIFLO和纤维蛋白胶可有效控制出血。硬质30°内镜有助于观察盲点和桥静脉附着情况，确保彻底清除SDH。随着时间推移对技术进行调整，我们通过尽量减少出血改善了患者预后，并提高了手术效果，从积极地将膜从硬脑膜上剥离（这可能引发出血）转变为专注于溶解不稳定的出血性膜，同时保留较薄的无出血膜。对于远处的膜性出血，SURGIFLO和纤维蛋白胶就足够了，避免在矢状旁和顶枕后部区域进行激进的溶解操作。
