The role of endoscope-assisted septectomy and membranectomy for complex chronic subdural hematomas: safety, efficacy, technical feasibility. Patient series

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BACKGROUND: Burr hole craniostomy and conventional craniotomy are respectively associated with high recurrence rates and morbidities in the evacuation of septated chronic subdural hematomas (CSDHs). The safety and efficacy of endoscope-assisted septectomy and membranectomy (ESM) via a mini-craniotomy are investigated in this subset of patients. OBSERVATIONS: Thirteen patients with a mean age of 75 ± 11.5 years and a median modified Rankin Scale (mRS) score of 4 were included. Surgeries had a mean craniotomy size of 3.6 ± 0.5 cm and a median duration of 142 minutes. Initial postoperative CT imaging confirmed complete hematoma evacuation. Six patients (46.2%) underwent perioperative middle meningeal artery embolization (MMAE) without complications. The mean length of hospital stay (LOS) was 8 ± 3.9 days. Lower preoperative Glasgow Coma Scale (GCS) scores (p = 0.049) and larger midline shifts (p = 0.024) were significantly associated with LOS > 5 days. Median mRS scores significantly improved at discharge (p < 0.015) and at the last follow-up (p < 0.009), yielding a low-tier mRS score (≤ 2) in 53.8% of patients at discharge and 92.3% favorable last follow-up outcomes. A higher admission GCS score was associated with a low-tier at-discharge mRS score (p = 0.048). Complete brain reexpansion occurred within a mean time of 6.2 ± 4.1 months, with no significant correlation with radiological and operative features or MMAE history. During a mean follow-up of 17.4 ± 13.4 months, no recurrences were observed. LESSONS: ESM is an effective, minimally invasive alternative for treating septated, multiloculated CSDH, offering minimal recurrences. Although operative times are longer, reduced reoperation rates and improved safety justify this strategy for complex hematomas. https://thejns.org/doi/10.3171/CASE25446.

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