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Trauma Case Reports 40 (2022) 100668
Available online 28 June 2022
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Case Report
Evacuation of a multi-loculated acute-on-chronic subdural
hematoma using tandem bedside subdural evacuation
port systems
John K. Yue
*
, Alexander F. Haddad, Albert S. Wang, David J. Caldwell,
Gray Umbach, Anthony M. Digiorgio, Phiroz E. Tarapore, Michael C. Huang,
Geoffrey T. Manley
Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States of America
Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States of America
ARTICLE INFO
Keywords:
Bedside hematoma evacuation
Subdural evacuation port system
Subdural hematoma
Traumatic brain injury
ABSTRACT
Background: Traumatic subdural hematomas (SDH) can have devastating neurologic conse-
quences. Acute-on-chronic SDHs are more frequent in the elderly, who have increased comor-
bidities and perioperative risks. The subdural evacuation port system (SEPS) procedure consists of
a twist drill hole connected to a single drain on suction, which can be performed at bedside to
evacuate SDHs without requiring general anesthesia. However, a single SEPS can be limited due
to inability to evacuate across septations between SDHs of different ages.
Purpose: We present to our knowledge the rst case of using tandem SEPS to evacuate a multi-
loculated SDH. We discuss the technical nuances of the procedure as a treatment option for
complex SDHs.
Findings: An 86-year-old man with cognitive impairment and recurrent falls presented acutely
after ground-level fall with worsening dysarthria and right hemiparesis. Computed tomography
scan showed a 11 mm left holohemispheric mixed-density SDH with loculated acute and sub-
acute/chronic components with 2 mm midline shift. Following two interval stability scans, the
patient underwent drainage of a supercial chronic component, and a posterolateral acute/sub-
acute component using two sequential SEPS drains at bedside in the intensive care unit. The
patient's symptoms markedly improved, drains were removed, and the patient was discharged
home with home health on post-procedure day 6.
Conclusions: Judicious patient selection and pre-procedural planning can enable the use of tandem
SEPS to evacuate multi-loculated SDHs under moderate sedation. Using multiple subdural ports to
evacuate complex SDHs should be an option for proceduralists in settings where general anes-
thesia is not feasible.
* Corresponding author at: Department of Neurological Surgery, University of California, San Francisco, 1001 Potrero Avenue, Bldg 1, Rm 101,
San Francisco, CA 94143, United States of America.
E-mail address: john.yue@ucsf.edu (J.K. Yue).
Contents lists available at ScienceDirect
Trauma Case Reports
journal homepage: www.elsevier.com/locate/tcr
https://doi.org/10.1016/j.tcr.2022.100668
Accepted 26 June 2022
Trauma Case Reports 40 (2022) 100668
2
Introduction
Chronic subdural hematomas (SDH) are frequently encountered by neurotraumatologists with an estimated annual incidence of
1–5/100,000, predominantly in the elderly [1]. Often due to rupture of cortical bridging veins initiated by trauma, acute-on-chronic
SDH can have devastating neurological consequences. Treatment options include evacuation (craniostomy, burr hole, craniotomy),
prevention (middle meningeal artery embolization) [2], and observation/medical management [3]. Inammatory pathways, angio-
genesis, and coagulopathy can lead to recurrent and/or loculated chronic SDHs, which pose challenges to evacuation [4].
The effects of comorbidities and perioperative risks for SDH evacuation are amplied in elderly patients, and have espoused
minimally invasive strategies. Bedside evacuation without the use of general anesthesia was rst reported in 1966 [5]. The Subdural
Evacuation Port System (SEPS) is a modern variant consisting of a single twist drill hole through the calvarium with puncture of dura
and connection to a Jackson-Pratt-type suction drain for negative pressure evacuation of SDH, and can be performed at the bedside [6].
The use of a single SEPS drain is associated with fewer postoperative complications, lower hospitalization costs, and shorter hospital
stays when compared to surgery [1].
However, single SEPS drains are often limited by view, and are at increased risk of puncturing vascularized septations in complex/
loculated SDHs. We present to our knowledge the rst case of using tandem SEPS to evacuate a multi-loculated SDH. We discuss the
management and technical nuances of the procedure as a treatment option for complex SDHs.
Case presentation
An 86-year-old man not on antiplatelet or anticoagulation agents, with progressive cognitive impairment and recurrent falls
presented acutely after ground-level fall with complaints of worsening dysarthria and right hemiparesis. On exam, Glasgow Coma
Scale score was 14 and decits included orientation to name and place but not year, inability to follow two-step commands, right
hemibody motor strength 4/5, and right pronator drift. Head computed tomography (CT) scan showed a 11 mm left holohemispheric
mixed-density SDH with loculated components, with 2 mm rightward midline shift (Fig. 1A-C). He was admitted to the intensive care
unit (ICU) for neurologic exams and received a seven-day course of phenytoin for post-traumatic seizure prophylaxis. He received two
interval CTs at 6 h and 18 h from admission, which showed stability of the SDH. Given his age, relative risks for anesthesia, and a stable
neurologic exam, SEPS was planned and informed consent was obtained. Conscious sedation was provided by the ICU anesthesia team.
First, a thick, supercial left frontal subacute/chronic component was targeted 17 cm posterior to the nasion and 6 cm left of
midline, above the superior temporal line. The SEPS twist drill hole was made and 20 mL of low-pressure, dark hygromatous uid was
evacuated. The patient's exam improved to oriented ×3. The SEPS drain was maintained to bulb suction and the patient underwent an
immediate head CT which showed decrease in the thickness of the SDH to 8 mm, and decrease in midline shift to 1.4 mm. It was evident
that the SEPS had evacuated a supercially-located subdural collection, and additional loculated hematomas remained especially
posterolaterally (Fig. 2A-C). A second SEPS was planned 2 cm posterior and 1 cm lateral to the initial twist drill hole, over the parietal
bossing.
The rst SEPS was placed off suction as the second twist drill hole was made, and 20 mL of thick, dark subacute SDH was evacuated.
The rst and second SEPS drains were alternated on and off suction over 15 min, with additional egress of 15 mL of dark blood. At this
time, small amounts of subacute SDH continued to exit into the rst drain, while the second drain no longer had output. To minimize
multiple pressure gradients across a contiguous subdural space, the second SEPS was removed and the incision was closed with suture.
Fig. 1. Initial Head CT, with left convexity SDH.
Caption: Initial head CT with 11–12 mm left holohemispheric, multi-loculated SDH, with axial slices through the level of the corona radiata (Panel
A) and coronal slice through the foramen of Monro (Panel C), with 2.3 mm of rightward midline shift (Panel B). CT =computed tomography; SDH
=subdural hematoma.
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Trauma Case Reports 40 (2022) 100668
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A subsequent CT showed that the SDH had decreased to 6 mm in maximum thickness, and focally to 3-5 mm at the anterior and
posterior twist drill hole sites, with resolution of midline shift (Fig. 3A-D). The patient's neurologic exam showed improved right
hemibody strength to 4 ±5.
Over the next 24 h, the drain output was 20 mL per 12 h shift. The patient regained the ability to follow complex commands, with
motor strength 5/5 and only a subtle right pronator drift. Post-procedure day 2 CT head showed stability, with a 6 mm anterior frontal
convexity (rather than holohemispheric) chronic SDH, without midline shift (Fig. 4A-C). The SEPS drain was removed on post-
procedure day 2 and the exit site was closed with suture. The patient continued to improve physically and cognitively while work-
ing intensively with physical, occupational and speech therapy, and progressed to discharge home with home health on post-procedure
day 6.
Discussion
Procedures for treating SDHs of different ages risk incomplete evacuation and reaccumulation, which may lead to residual
symptoms and reoperation. Across meta-analyses, the success rate of SEPS has been cited at 77–79 % with a 15–22 % recurrence rate
and low morbidity of 1–2 % [1]. The efcacy of SEPS versus burr holes have been reported as similar across most studies [7,8], Given
the benets of not requiring general anesthesia or operating room time methodological improvements of SEPS use across clinical
settings is benecial for patient outcomes. While one historical report of the SEPS technique stated the possibility of using more than
one port [6], to our knowledge this is the rst case report describing tandem SEPS use for the evacuation of loculated SDHs.
Our case shows that when judiciously planned based on radiographic characteristics, multiple SEPS can be used to evacuate
loculated SDHs, which are traditionally difcult to evacuate [9] and beyond the capabilities of a single SEPS. Interval imaging can be
used in-between SEPS placements to determine the extent and/or limits of evacuation from the rst SEPS, and relative changes in
morphology of other loculations subsequent to the effects of the rst SEPS. Precise measurements should be taken based on anatomical
landmarks prior to the placement of the second drain, as intracranial contents may have shifted. The provider should be mindful of the
potential of multiple negative pressures on the intracranial space, and in our case the bulbs of each drain was set to “off suction” during
placement, and with only one drain on suction at any time during active evacuation. The placement of one drain “on suction” with
negative pressure, and the other “off suction”, simulates the effects of the positive pressure that encourages subdural uid egress
between two burr holes [10].
Limitations
Our case study was performed at a well-resourced tertiary trauma center capable of acquiring urgent CT imaging within the hour,
with the support of anesthesia and ICU staff. Other limitations include the favorable anatomy and physiology of the patient and the
availability of multiple SEPS drains. We did not assess the effects of keeping multiple SEPS drains to suction. Our ndings and these
limitations await validation in larger studies across more diverse ages and SDH morphologies.
Fig. 2. Head CT, after rst SEPS.
Caption: Head CT after implantation of the rst SEPS 17 cm posterior to the nasion and 6 cm left of midline, with evacuation of a supercial chronic
component (best seen in Panel C, intracranial and medial to the SEPS drain location). The left convexity SDH improved to 7–8 mm in thickness
(Panel A and C), and midline shift improved from 2.3 mm to 1.4 mm (Panel B). CT =computed tomography; SEPS =subdural evacuation port
system; SDH =subdural hematoma.
J.K. Yue et al.
Trauma Case Reports 40 (2022) 100668
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Fig. 3. Head CT, after second SEPS.
Caption: Head CT after implantation and removal of the second SEPS 2 cm posterior and 1 cm lateral to the rst SEPS, with evacuation of a separate, lateral subacute SDH. Panel A and B show the more
anterior component of the SDH and unchanged location of the rst SEPS, with improvement of the convexity SDH to 4–6 mm. Panel C and D show the more posterior component of the SDH, which has
also improved to 6 mm in thickness. CT =computed tomography; SEPS =subdural evacuation port system; SDH =subdural hematoma.
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Trauma Case Reports 40 (2022) 100668
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Conclusions
Judicious patient selection and pre-procedural planning can enable successful use of tandem SEPS to evacuate multi-loculated
SDHs under moderate/conscious sedation. Interval imaging can be obtained between successive SEPS to guide iterative placement
of drains. The use of multiple subdural ports to evacuate complex SDHs should be an option for proceduralists in settings where general
anesthesia is not feasible.
Previous presentations
None.
Funding
This study was unfunded.
Declaration of competing interest
None.
Acknowledgments
None.
References
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Fig. 4. Head CT, post-procedure day 2.
Caption: Head CT post-procedure day 2 after SEPS implantation. Panel A and C show further decrease in the thickness of the left convexity SDH, now
6 mm frontally and 3 mm posteriorly. Panel B shows that the prior midline shift has resolved. CT =computed tomography; SEPS =subdural
evacuation port system; SDH =subdural hematoma.
J.K. Yue et al.
