Endoscopic-assisted evacuation of chronic subdural hematomas – A retrospective analysis and a literature review

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly in elderly patients. Burr-hole craniectomy (BHC) remains the standard treatment; however, endoscopic-assisted (EA) techniques have been increasingly adopted to improve visualization of the subdural space, facilitate membranectomy, and enhance hemostasis. We report a single-center retrospective comparison between BHC and EA for CSDH evacuation and review the current literature on the role of endoscopy in this setting. Methods: Patients undergoing surgical evacuation of CSDH over a 1-year period were retrospectively analyzed. All procedures were performed by a single surgeon. Patients were divided into BHC and EA groups. Demographic, clinical, radiological, and operative variables, as well as postoperative outcomes, were compared. A systematic literature review was also conducted. Results: Twenty-one patients were included (14 BHC, 7 EA). All EA cases presented with organized hematomas and membranes on preoperative imaging. Mean operative time for EA was 62.5 min, and no drains were used. EA provided circumferential visualization of the subdural cavity, allowing targeted membranectomy and precise hemostasis. Patients in the EA group demonstrated significant postoperative functional improvement and pain reduction, with no recurrences or complications observed. Radiological resolution was slower compared to BHC. Literature review showed that 15 of 16 studies favored endoscopic assistance, particularly for organized or septated hematomas. Conclusion: EA evacuation appears safe and effective in selected CSDHs with organized membranes. Direct visualization of the subdural space may improve surgical control and potentially reduce recurrence risk.