Endoscopic evacuation of septated chronic subdural hemorrhage – Technical considerations, results, and outcome

Background: Chronic subdural hematoma (cSDH) is a common entity in the elderly. Homogeneous or well-liquefied CSDH has a standard line of treatment through burr hole and irrigation. However, the management of septated chronic subdural hematoma (sCSDH) with multiple membranes does not have a well-defined surgical approach. The neomembranes forming septations prevent evacuation of clots through burr holes, and the small remaining loculi with clots will enlarge overtime to cause recurrence. Methods: Patients with sCSDH were operated through a minicraniotomy (2.5 cm × 2.5 cm) using rigid endoscopes for visualization of the subdural space. Using endoscope, the entire subdural space can be visualized. The neomembranes are removed with standard neurosurgical microinstruments. The entire cavity is irrigated under vision to remove all clots and ensures hemostasis. Results: Eighty-three endoscope-assisted evacuations were done in 68 patients from January 2016 to April 2020. Fifty (73.5%) patients had unilateral and 18 (26.5%) had bilateral subdural. Only 1 patient (1.47%) had a clinically significant recollection of subdural bleeding 1 month after the procedure. Over a mean follow-up period of 25.3 months (range 1–53 months), rest of patients did not show any recollection. Conclusion: Endoscopic evacuation of sCSDH is a safe and effective method and can be used to improve clot evacuation, and remove neomembranes under direct vision to reduce the rates of recollection. This method also obviates the need for larger craniotomies to remove membranes.

The application of augmented reality–based navigation for accurate target acquisition of deep brain sites: advances in neurosurgical guidance

OBJECTIVE The objective of this study is to quantify the navigational accuracy of an advanced augmented reality (AR)–based guidance system for neurological surgery, biopsy, and/or other minimally invasive neurological surgical procedures. METHODS Five burr holes were drilled through a plastic cranium, and 5 optical fiducials (AprilTags) printed with CT-visible ink were placed on the frontal, temporal, and parietal bones of a human skull model. Three 0.5-mm-diameter targets were mounted in the interior of the skull on nylon posts near the level of the tentorium cerebelli and the pituitary fossa. The skull was filled with ballistic gelatin to simulate brain tissue. A CT scan was taken and virtual needle tracts were annotated on the preoperative 3D workstation for the combination of 3 targets and 5 access holes (15 target tracts). The resulting annotated study was uploaded to and launched by VisAR software operating on the HoloLens 2 holographic visor by viewing an encrypted, printed QR code assigned to the study by the preoperative workstation. The DICOM images were converted to 3D holograms and registered to the skull by alignment of the holographic fiducials with the AprilTags attached to the skull. Five volunteers, familiar with the VisAR, used the software/visor combination to navigate an 18-gauge needle/trocar through the series of burr holes to the target, resulting in 70 data points (15 for 4 users and 10 for 1 user). After each attempt the needle was left in the skull, supported by the ballistic gelatin, and a high-resolution CT was taken. Radial error and angle of error were determined using vector coordinates. Summary statistics were calculated individually and collectively. RESULTS The combined angle of error of was 2.30° ± 1.28°. The mean radial error for users was 3.62 ± 1.71 mm. The mean target depth was 85.41 mm. CONCLUSIONS The mean radial error and angle of error with the associated variance measures demonstrates that VisAR navigation may have utility for guiding a small needle to neural lesions, or targets within an accuracy of 3.62 mm. These values are sufficiently accurate for the navigation of many neurological procedures such as ventriculostomy.

Surgical management of chronic subdural hematomas through single-burr hole craniostomy: is it sufficient?

Background Symptomatic chronic subdural hematomas (CSDH) remain one of the most encountered forms of intracranial hemorrhages particularly in the elder patients, yet fortunately implies a good surgical prognosis. Burr hole evacuation under general anesthesia is the most commonly used neurosurgical technique for the management of CSDH. Clinical disagreement between many studies regarding the number of burr holes required to achieve the optimal surgical and clinical outcome has long existed. The objective of this study is to evaluate the prognosis and clinical outcome following the use of single-burr hole craniostomy technique in the aim of surgical evacuation of CSDH. Results This is a retrospective study of 30 patients, with symptomatic unilateral or bilateral CSDH managed by the authors strictly by single-burr hole evacuation with closed-system drainage on the corresponding site of the hematoma. Clinical outcome was then assessed at 1, 7, and 30 days after surgery using the Glasgow Coma Scale (GCS) and by comparing the Markwalder grade scale before surgery to 1 month following surgery; the pre- and post-operative radiological data, clinical neurological progress and the possible incidence of complications postoperatively were also recorded. Study duration was from August 2019 to October 2020. Our study included 18 (60%) male patients and 12 (40%) female patients. The main presenting symptom was altered level of consciousness noted in 29 (96.7%) patients; a history of a relevant head trauma was recorded in 11 patients (36.7%). The GCS showed a statistically highly significant improvement comparing the preoperative to the postoperative values throughout the follow-up intervals (p = 0.001); similarly, the Markwalder score significantly improved 1 month after surgery, where 17 (63%) patients were Markwalder grade 0, 9(33.3%) patients were grade 1, a single patient (3.7%) was grade 2, and none were Markwalder grade 3. Conclusion Our study concluded that single-burr hole craniostomy with closed-system drainage for the management of symptomatic CSDH would be a sufficient approach to achieve a good surgical outcome with a low complication rate. Larger series and further studies would be yet considered with longer follow-up periods.

Comparative study of subdural drain (SDD) versus sub periosteal drain (SPD) in treating patient with chronic subdural hematoma (CSDH)

Background: Chronic subdural hematoma (CSDH) is common neurosurgical condition encountered in daily practice. Burr holes evacuation is standard treatment for symptomatic cases. Both subdural drain (SDD) and subperiosteal drain (SPD) have been reported to lower the recurrence rate when used in conjunction with burr holes. A randomized controlled trials were done to see if there were any differences in clinical and radiographic outcomes between the two types of drains. Methods: A total of 42 CSDH patients were enrolled and allocated to one of two groups: SDD (n = 21) or SPD (n = 21). Demographic data, perioperative imaging characteristics, clinical outcome, and recurrence rate were recorded for comparison. Results: In both groups, demographic characteristics such as sex ratio, mean age of patients, concomitant disease, and antithrombotic agent use were similar. At 6 months, 20 (95.2%) and 21 (100%) cases in the SDD and SPD groups, respectively, had a favorable outcome (mRS 0–3). Complete hematoma resolution at 6 months was achieved in 21 (100%) and 19 (90.5%) cases of the SDD and SPD groups, respectively. The amount of drain within 48 h was not difference between the two groups. None of the SDD recurred, but two of the SPD group did, necessitating reoperation, which had no effect on the final outcome. Conclusion: These findings indicate that the drain type (SDD or SPD) has no effect on the outcome. The surgeon’s preference determines which procedure is used. Except in symptomatic circumstances, routine postoperative imaging may not be required.

Long-term clinical and radiographic outcomes after pial pericranial dural revascularization: a hybrid surgical technique for treatment of anterior cerebral territory ischemia in pediatric moyamoya disease

OBJECTIVE Isolated anterior cerebral artery (ACA) territory ischemia in pediatric moyamoya disease (MMD) is rare but has been increasingly recognized, particularly in children manifesting progression of disease in a delayed fashion after middle cerebral artery revascularization surgery. Surgical treatment is complicated by limited graft choices, with the small number of case series largely focused on complex, higher-risk operations (omental flap transfers, large interhemispheric rotational grafts); direct bypass (often untenable in children due to vessel size); or, alternatively, the technically simpler method of multiple burr holes (of limited efficacy outside of infants). Faced with the problem of a growing cohort of pediatric patients with MMD that could benefit from anterior cerebral revascularization, the authors sought to develop a solution that was specifically designed for children and that would be lower risk than the more complex approaches adapted from adult populations but more effective than simple burr holes. In this study, the authors aimed to describe the long-term clinical and radiographic outcomes of a novel approach of pial pericranial dural (PiPeD) revascularization, building on the principles of pial synangiosis but unique in using the pericranium and the dura mater as the primary vascular supply, and employing a larger craniotomy with arachnoid dissection to provide robust full-territory revascularization in all ages with reduced risk relative to more complex procedures. METHODS The medical records of all pediatric patients with MMD who presented at a single center between July 2009 and August 2019 were retrospectively reviewed to identify patients with MMD with anterior cerebral territory ischemia. Clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic follow-up data were collected and analyzed. RESULTS A total of 25 operations (5.6% of total procedures) were performed in 21 patients (mean age 9.4 years [range 1–16.5 years]; 12 female and 9 male). Almost one-third of the patients had syndromic associations, with no familial cases. Complications included 1 patient (4.7%) with a superficial infection, with no postoperative strokes, hemorrhage, seizures, or deaths. Long-term follow-up was available in 18 of 21 patients (mean 24.9 months [range 4–60 months]). Radiographic engraftment was present in 90.9% (20/22 hemispheres), and no new strokes were evident on MRI on long-term follow-up, despite radiographic progression of the disease. CONCLUSIONS The use of the pericranium and the dura mater for indirect revascularization provided robust vascularized graft with great flexibility in location and high potential for engraftment, which may obviate more complex and higher-risk operations for ACA territory ischemia. Long-term follow-up demonstrated that PiPeD revascularization conferred durable, long-term radiographic and clinical protection from stroke in pediatric patients with MMD. Based on the results of the current study, the PiPeD technique can be considered an additional tool to the armamentarium of indirect revascularization procedures in select pediatric patients with MMD.

Subdural false twins: concomitant appearance of subdural haematoma and spontaneous subdural empyema

A 55-year-old man was taken to the emergency department due to right arm weakness for the past 3 days and fever (39.5°C). There was no impaired consciousness, no history of trauma and meningeal signs were absent on physical examination. Blood analysis and inflammatory markers were not evocative of a systemic infection. A cranial CT scan was requested, revealing hypodense bilateral hemispheric subdural collections, suggestive of chronic subdural haematomas. He was submitted to surgical drainage by burr holes, which confirmed the chronic subdural collection on the left side. Unexpectedly, after dural opening on the right side, a subdural purulent collection was found, which was later confirmed as an empyema due to Escherichia coli infection. A second surgical drainage was performed by craniotomy due to recurrence of the right subdural collection. Spontaneously appearing subdural empyemas due to E. coli are extremely rare and their treatment is not always straightforward. The reported case is an example of an apparently straightforward and frequent pathology that turned out to be a challenging case, requiring a multidisciplinary approach.

Skull Modulated Strategy to Intensify Tumor Treating Fields on Brain Tumor: a Finite Element Study

Purpose Tumor treating fields (TTFields) are a breakthrough in treating glioblastoma (GBM). Whereas, the intensity cannot be further enhanced, due to the limitation of scalp lesions. Skull remodeling (SR) surgery can elevate the treatment dose of TTFields in the intracranial foci. This study was aimed at exploring the characteristics of SR surgery towards TTFields augmentation. Methods The simplified multiple-tissue-layer model (MTL) model and realistic head (RH) model were reconstructed through finite element methods (FEM), to simulate the remodeling of the skull, which included skull drilling, thinning, and cranioplasty with PEEK, titanium, cerebrospinal fluid (CSF), connective tissue and autologous bone. Results Skull thinning could enhance the intensity of TTFields in the brain tumor, with a 10% of increase of average peritumoral intensity (API) by every 1 cm decrease in skull thickness. Cranioplasty with titanium accompanied the most enhancement of TTFields in the MTL model, but CSF was superior in TTFields enhancement when simulated in the RH model. Besides, API increased nonlinearly with the expansion of drilled burr holes. In comparison with the single drill replaced by titanium, 9 burr holes could reach 96.98% of enhancement in API, but it could only reach 63.08% of enhancement under craniectomy of 9-times skull defect area. Conclusion Skull thinning and drilling could enhance API, which was correlated with the number and area of skull drilling. Cranioplasty with highly conductive material could also augment API, but might not provide clinical benefits as expected. Keywords Tumor treating fields, skull remodeling, cranioplasty, skull replacement, brain tumor, finite element analysis

Combined dural inversion with multiple burr holes for refractory chronic subdural hematoma: A case report.

Background: Chronic subdural hematoma（CSDH） is a common disease in neurosurgery department. Burr-hole drainage is the main surgical treatment. And the recurrence rate is as high as 25%.Case presentation: In this case, a male patient with CSDH in the left frontotemporal parietal region underwent two drilling and drainage operations in the local hospital, but the hematoma recurred after operations. Being unable to bearing the repeated and progressive aggravation of headache, he came to our hospital for treatment. After considering the comprehensive situation, we use a new surgical method, removal of hematoma by drilling multiple holes in the lateral skull, to cure the patient.Conclusions: we get inspirations from the therapy for moyamoya disease, combining dura mater inversion and hole burr, the scalp forms many "meat column" like structures which have powerful capability in absorption through the bone holes, so the scalp could deep into the hematoma, then the CSDH could be cured. This case Provide a new surgical method for the treatment of refractory CSDH. Key words: CSDH R ecur Bone hole Scalp Dural mater inversion