Endoscopic Lavage of Extensive Chronic Subdural Hematoma in an Infant After Abusive Head Trauma: Adaptation of a Technique From Ventricular Neuroendoscopy

Abstract

Subdural fluid collections are frequently encountered in young children after non-accidental injury. In a subset of patients, these collections progress in size and ultimately require permanent drainage, which is commonly achieved with subdural-peritoneal shunts. However, excessive protein and cellular contents in the fluid are potential risk factors for shunt failure. Here, we describe the adaptation of an endoscopic lavage technique established for ventricular endoscopy with the aim of improving fluid condition prior to shunting. We present a case of subdural fluid collections secondary to non-accidental injury, where permanent shunting was required but could not be performed due to excessive protein and cellular levels in the subdural fluid despite conventional burr hole drainage. A two-month-old male infant presented with a bulging and tense fontanel, a reduced level of consciousness, bradycardia, and significant macrocephaly. Computed tomography (CT) demonstrated massive bilateral, low attenuation subdural fluid collections, reaching a diameter of 4.5 cm. Emergency burr hole washout and insertion of subdural drains was performed. Despite prolonged drainage over 10 days, the protein level remained at 544 mg/dl and the mean erythrocyte count at 6,493/µl. Continuous drainage was required to avoid clinical deterioration due to raised intracranial pressure; however, the fluid condition was still considered incompatible with permanent subdural-peritoneal shunting. We, therefore, performed an endoscopic subdural lavage with a careful evacuation of residual blood deposits. No complications were encountered. Postoperatively, mean protein level was 292 mg/dl and mean erythrocyte count was 101/µl. Endoscopic lavage could be safely performed in a case of extensive subdural low attenuation fluid collections, where conventional burr hole drainage failed to improve protein and cellular contents as a prerequisite for successful permanent shunting. We conclude that adaptation of this technique can be helpful in selected cases as an alternative procedure.

Endoscopic Management of Chronic Subdural Hematoma

“…Endoscopic lavage before shunting can remove protein and cellular debris to improve the success rate of shunt surgery. 4 Although there was no infant in our series, endoscopic evacuation of subdural hematomas was also found to be effective in infants. 18 Although we did not come across any recurrence in our series, it could be due to the small number of cases with a short follow-up.…”

“…It provides good visualization compared with the flexible scope. There are reports of use of both rigid [1][2][3][4]8,10,[12][13][14]17,19,21 and flexible scopes 5,9,11 in the management of CSDH. There may be difficulty in advancing the rigid scope, especially when the bony opening is not selected properly.…”

Neuroendoscopic Approach of a Massive Bilateral Chronic Subdural Hematoma in a Child Using a Single Burr Hole

“…In this case, we selected neuroendoscopy because of the massive collection of fluid in the subdural space. In addition, few studies have reported its use in drainage of chronic subdural hematomas [ 2 - 5 , 8 ]. To our knowledge, this is the second report of the use of neuroendoscopy to approach massive bilateral chronic subdural hematomas in children [ 2 ].…”

“…In addition, few studies have reported its use in drainage of chronic subdural hematomas [ 2 - 5 , 8 ]. To our knowledge, this is the second report of the use of neuroendoscopy to approach massive bilateral chronic subdural hematomas in children [ 2 ]. However, despite the presence of a bilateral chronic hematoma, non-accidental head trauma was ruled out after deep investigation to the best of our knowledge.…”

“…The management of subdural fluid collection in infants is controversial, and several treatment modalities have been reported, such as fontanelle puncture and drainage, burr hole irrigation, and subduroperitoneal shunt [1]. A few studies have also reported neuroendoscopy for evaluating chronic subdural hematomas [2][3][4]. The main advantages of neuroendoscopy are accurate visualization of the subdural space and minimal invasiveness [5].…”