Case Report: Subdural evacuating port system for the management of acute on-chronic subdural hemorrhage

Background: Traumatic subdural hematomas (SDHs) carry high morbidity and mortality without timely decompression, posing major challenges in settings lacking immediate neurosurgical support. Case Description: A 75-year-old man with hypertension and hyperlipidemia on aspirin fell from a 3-foot ladder sustaining brief loss of consciousness. He presented with amnesia, headache, and nausea with Glasgow Coma Scale (GCS) 15. Computed tomography of the head (CTH) showed subarachnoid hemorrhage and bilateral SDH with acute and chronic components (left: 9 mm, right: 7 mm). Four hours later, GCS declined to 10 (E2V3M5) with the motor examination notable for localization to pain on the right and absent response on the left. Anisocoria also developed, with a fixed, non-reactive right pupil (4.6 mm, NPi 0) and a reactive left pupil (3.2 mm, NPi 2.9). Repeat CTH demonstrated SDH expansion (left: 17mm, right: 11mm). The patient was intubated and underwent right-sided subdural evacuating port system (SEPS) drainage (674 cc cumulative output over 2 days). Follow-up CTH showed reduction of the right SDH to 5 mm and left to 14 mm. His examination improved to GCS 11T; he was extubated the next day. He subsequently underwent middle meningeal artery embolization 4 weeks later. CTH 7 months post-injury demonstrated near-complete resolution of bilateral SDHs. Conclusion: SEPS is well established for the management of chronic SDHs. This case illustrates its use as an emergent, temporizing bridge in a patient with a mixed acute-on-chronic collection and rapidly evolving intracranial hypertension, followed by adjunctive middle meningeal artery embolization to promote durable resolution. This combined approach may be considered in select patients with elevated intracranial pressure when definitive neurosurgical care is unavailable or delayed.