BE: Hellwig D, Kuhn TJ, Bauer BL, List-Hellwig E, Endoscopic treatment of septated chronic subdural hematoma. Surg Neurol 1996;45:272-7. The authors reported their experience using a flexible steerable endoscope to treat septated subdural hematomas in 14 patients. Twelve patients had sufficient or complete hematoma evacuation; one underwent a second operation, and one had a postoperative subdural infection. Long-term follow-up showed no instance of recurrence of the subdural hematoma. To the Editor: I read with interest the article by Hellwig et al. While I applaud the emphasis given to the recognition of the septate (or multiloculated) variant of chronic subdural hematoma (CSDH), I disagree with the central theme of the article, stipulating that burr hole evacuation in a septate CSDH is bound to fail. Since imaging techniques are not reliable in identifying the septate variant of CSDH, a high index of suspicion for it and careful search for septations at surgery is crucial. Partial resection of septations at surgery via a two-burr hole approach followed by a closed drainage system will result in complete resolution of the CSDH in the vast majority of cases [l]. Under these circumstances, the need for this elegant endoscopic technique will arise very infrequently. Allan
SUBDURAL-PERITONEAL FOR SDH
BE: Misra M, Salazar JL, Bloom DM. Subduralperitoneal shunt: treatment for bilateral chronic subdural hematoma. Surg Neurol 1996;46:378-83. The authors report a case of recurrent bilateral chronic subdural hematoma in an adult, which was successfully managed by repeated burr hole evacuation initially, followed by insertion of a subduralperitoneal shunt. In cases of chronic SDH that do not respond well to regular treatment, they recommend the placement of a subdural-peritoneal shunt in preference to a more complicated craniotomy and membranectomy. To the Editor: This paper does illustrate the feasibility of draining a chronic liquid subdural hematoma in elderly patients. The fact that these do recur is widely known. However, not as widely known is the fact that one can put an on-off Portnoy device between the reservoir in the ventricle and the Holter valve that leads to the peritoneal shunt. Under those circumstances, fluid can be aspirated from the subdural hematoma through a drill hole and the shunt can be kept closed until the scan shows that the subdural has diminished in size to an acceptable level. The shunt can then be opened again simply by pressure on the scalp. This particular procedure has been used frequently and was described in Apuzzo’s Brain Surgery: Complications, Avoidance and Management (New York: Churchill Livingstone, 1992). The ease with which one can open and close the on-off device in the office recommends this to all those treating chronic conditions.
1. Drapkin AJ. Chronic subdural hematoma: pathophysiological basis for treatment. Brit J Neurosurg 1991;5:467-73.
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