Endoscopic Hematoma Evacuation Under Local Anesthesia for Acute Intracerebral Hemorrhage in Older Patients: A Case Series

Intracerebral hemorrhage (ICH) is a severe neurological condition with a poor prognosis, and surgical intervention is often necessary in cases with significant hematoma volume. With the progression of a super-aging society, the incidence of ICH in older patients is increasing. However, traditional craniotomy under general anesthesia poses a high risk to older patients, thereby limiting its use. Recently, minimally invasive techniques have become widely used. Endoscopic hematoma evacuation can be performed under local anesthesia, which may minimize invasiveness and reduce the risk of complications associated with general anesthesia in older patients. However, only a few studies have specifically addressed endoscopic hematoma evacuation under local anesthesia for acute ICH in older patients, and the optimal protocol for surgical procedures and perioperative management remains unclear. The aim of this study is to highlight the technical considerations and potential benefits of endoscopic surgery for ICH in older patients. This study presents a case series of five patients aged ≥ 70 years who underwent endoscopic hematoma evacuation under local anesthesia for acute ICH. The median hematoma removal rate was 95.8%, with no postoperative re-bleeding or mortality. 3D visualization technology using preoperative computed tomography images not only facilitates the initiation of surgery but also assists with intraoperative support for accurate hematoma localization. In older patients, preoperative insertion of a nasogastric tube and the use of a transparent drape were effective in ensuring intraoperative airway management. Our findings suggest that endoscopic hematoma evacuation under local anesthesia is a safe and effective treatment option for older patients, offering reduced surgical invasiveness while maintaining high removal rates.