Endoscopic subdural membranectomy for multi-septated chronic subdural hematoma: Finding a safe solution when middle meningeal artery embolization is not feasible

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.