J Korean Neurosurg Soc.  2023 Sep;66(5):552-561. 10.3340/jkns.2023.0064.

Endoscopic Treatment of Chronic Subdural Hematoma Combined with Inner Subdural Hygroma

• Park YH
• Kim KR
• Kim KH

• KMID: 2545346
• DOI: http://doi.org/10.3340/jkns.2023.0064

Abstract

Objective
: A chronic subdural hematoma (CSDH) is a collection of bloody fluid located in the subdural space and encapsulated by neo-membranes. An inner subdural hygroma (ISH) is observed between the inner membrane of a CSDH and the brain surface. We present six cases of CSDH combined with ISH treated via endoscopy.
Methods
: Between 2011 and 2022, among the 107 patients diagnosed with CSDH in our institute, six patients were identified as presenting with CSDH combined with ISH and were included in this study. Preoperative computerized tomography (CT) and magnetic resonance imaging (MRI) were performed simultaneously, and endoscopic surgery for aspiration of the hematoma was performed in all cases of CSDH combined with ISH.
Results
: The mean age of patients was 71 years (range, 66 to 79). The patients were all male. In two cases, the ISH was not identified on CT, but was clearly seen on MRI in all patients. The inner membrane of the CSDH was tense and bulging after draining of the CSDH in endoscopic view due to the high pressure of the ISH. After fenestration of the inner membrane of the CSDH and aspiration of the ISH, the membrane was sunken down due to the decreasing pressure of the ISH. There was one recurrence in post-operative 2-month follow up. The symptoms improved in all patients after surgery, and there were no surgery-related complications.
Conclusion
: CSDH combined with ISH can be diagnosed on imaging, and endoscopic surgery facilitates safe and effective treatment.

Keyword

Hematoma, subdural, chronic; Endoscopy

Figure

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  Fig. 1. A : Preoperative computerized tomography showing the chronic subdural hematoma (white arrow) and inner subdural hygroma (open arrow). B : The chronic subdural hematoma (white arrowhead) of trabecular type and homogeneous inner subdural hygroma (open arrowhead) on T2-weighted image. C : The inner membrane (curved arrow) between the chronic subdural hematoma and inner subdural hygroma is showed as the dark signal on the T2-weighted image.

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  Fig. 2. A : Preoperative computerized tomography showing the chronic subdural hematoma and inner subdural hygroma on the left side. B-F : Preoperative magnetic resonance sequences showing the chronic subdural hematoma and inner subdural hygroma; T2 weighted image (B), T1- weighted image (C), flair (D), diffusion-weighted imaging (E), and coronal T1 weighted image (F).

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  Fig. 3. A : Endoscopic view after opening of dura and outer membrane of chronic subdural hematoma. The remnant of the outer membrane (white arrow) and the inner membrane of chronic subdural hematoma (open arrow). The inner membrane is very tense and translucent but not clear. B : After fenestration of the inner membrane and draining of the inner subdural hygroma, the inner membrane (white arrowhead) is sunken down and the brain surface (open arrowhead) was showed clearly. C : Endoscopic view of a recurrent case. The inner membrane is very thick (black asterisk). The fibrous septa (white asterisk) of trabecular type are revealed in the chronic subdural hematoma space.

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  Fig. 4. Preoperative images of illustrative case 1. A : Inner subdural hygroma is not clearly seen on computerized tomography scan. B and C : The chronic subdural hematoma and inner subdural hygroma with compressed left hemisphere is showed on T1-weighted image (B) and diffusion-weighted imaging (C).

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  Fig. 5. Endoscopic view of illustrative case 1. A : The bulging inner membrane of the chronic subdural hematoma (open arrow) and narrowed chronic subdural hematoma space (white arrow). B : After fenestration of the inner membrane, the chronic subdural hematoma space is widened (white arrowhead) and the brain surface (open arrowhead) is showing via the opening of the inner membrane.

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  Fig. 6. Preoperative image of illustrative case 2. A : The separated type of chronic subdural hematoma on the right-side hemisphere is demonstrated on computerized tomography, however, inner subdural hygroma is not identified. B : The inner subdural hygroma is revealed well on magnetic resonance imaging.

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  Fig. 7. Endoscopic view of illustrative case 2. A : The inner membrane is tense and gray (open arrow), and the chronic subdural hematoma space is narrowed (white arrow). B : After incision of the inner membrane (white asterisk), the inner membrane is sunken down, and the spaces of chronic subdural hematoma and inner subdural hygroma is observed widely. The remnant chronic subdural hematoma (white arrowhead) is also observed.

Reference

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