The Feasibility of Neuroendoscopic Fenestration in Septated Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES: We aimed to evaluate the feasibility of neuroendoscopic fenestration (NEF) for the treatment of septated chronic subdural hematoma (scSDH), in comparison with burr hole drainage (BHD) and craniotomy. METHODS: A retrospective analysis of 115 scSDH surgeries conducted from 2021 to 2026 at a single institution revealed 71 BHD procedures (61.7%), 34 NEF procedures (29.6%), and 10 craniotomies (8.7%), with NEF performed as either a primary treatment for septations or as a salvage after BHD failure. Outcomes were assessed through volumetric analysis on follow-up computed tomography and recurrence leading to reoperation. RESULTS: Postoperative hematoma in the NEF group was significantly lower (40.59 ± 47.06 cm3) than that in the BHD (74.07 ± 58.32 cm3, P = .012). The percentage reduction in hematoma was greatest with NEF (-71.74% ± 28.57%) compared with BHD (-44.89% ± 39.66%) and craniotomy (-61.96% ± 46.00%) (P = .003). On univariable analysis, NEF was associated with a significantly lower risk of reoperation compared with BHD (odds ratio [OR], 0.261; 95% CI, 0.082-0.827; P = .022). Multivariable analysis confirmed that smaller postoperative volume (OR, 1.022; 95% CI, 1.011-1.033; P < .001) and greater percentage reduction (OR, 1.033; 95% CI, 1.017-1.050; P < .001) were independent predictors of reduced recurrence, irrespective of the surgical method. NEF demonstrated significantly lower postoperative volume and greater percentage reduction compared with BHD (P = .012 and P = .002, respectively). CONCLUSION: NEF showed better hematoma clearance and a lower recurrence rate than BHD, with a similar incision size. It is a viable primary option for scSDH and an appropriate alternative after unsuccessful BHD, without requiring a larger incision.