{"id":"20cb1a81-2bc3-499f-96a4-6c3eb31afbc9","slug":"endoscopic-subdural-membranectomy-for-multi-septated-chronic-subdural-hematoma-finding-a-safe-solution-when-middle-meningeal-artery-embolization-is-not-feasible","title":"Endoscopic subdural membranectomy for multi-septated chronic subdural hematoma: Finding a safe solution when middle meningeal artery embolization is not feasible","authors":["Adnan Hussain Shahid","Mehdi Khaleghi","Sudhir Suggala","Garrett Dyess","Maxon Basett","Danner Warren Butler","Asa Barnett","Ursula Hummel","Danielle Chason","Jai Deep Thakur"],"abstract":"Background: 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. Case Description: 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. Conclusion: 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. Endoscopic subdural membranectomy for multi-septated chronic subdural hematoma 000:14 – Clinical presentation 0.00:38 - Preoperative neuroimaging 0.01:14 – Rational for the procedure 0.01:37 – Potential benefits and risks of the procedure 02.23 – Alternatives and reasons such approaches were not chosen 03:16 – Procedure set up 03:34 – Surgical steps 04:07 – Frontoparietal mini-craniotomy 04:16 – Coagulation of septa 04:55 – Cutting of septa 05:18 – Coagulation of outer subdural membrane 06:49 – Coagulation of the inner subdural membrane 07:04 – Peeling of inner subdural membrane 08:07 – Final inspection 08:13 – Disease background The Institutional Review Board approval is not required. The authors certify that they have obtained all appropriate patient consent. There are no conflicts of interest. The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/placeholders/specialty/neuroendoscopy.png","publishDate":"2025-05-30T00:00:00.000Z","doi":"10.25259/SNI_340_2025","categories":["Neuroendoscopy","Video Abstract"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/20cb1a81-2bc3-499f-96a4-6c3eb31afbc9/pdf"}