OBJECTIVE Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas. METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient's scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma. RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40-70 minutes). The actual endoscopic operating time was 30 (range 15-50) minutes. The median blood loss was 80 (range 40-150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01). CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma's location to achieve satisfactory hematoma removal.

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Background Endoscopic removal of subacute subdural hematoma is seldom performed, but there is no standard technique till date. We investigated whether a simple endoscopic method is effective for the evacuation of subacute subdural hematoma. Methods A total of 51 patients with subacute subdural hematoma requiring surgery were enrolled in this study. Endoscopic hematoma evacuation was performed through a small bone window for 22 patients. Hematoma evacuation by open surgery was performed in 29 patients. Pre- and postoperative Glasgow coma scale (GCS), operation time, displacement of midline, and intraoperative blood loss were recorded and analyzed. Results The median time from incision to suture completion was 40 min (range: 31.25–43.75 min) for endoscopic group, and 70 min (range: 65–80 min) for open surgery group (P<0.01). The average total blood loss was 50(30-50) ml for endoscopic group, and 250(200-300) ml for open surgery group (P<0.01). No patient showed post-operative re-bleeding in both groups. The mean preoperative mid-line displacement for the two groups was 11.51±3.51mm for study group vs 10.47±2.93mm for control group (P>0.05). Mid-line displacement showed significant improvement on the day after surgery to 5.29±1.91mm for study group vs 6.75±1.37mm for control group (P<0.01). At 1-month follow-up, the midline was normal in both groups. Computed tomography revealed almost no residual hematoma, representing an average evacuation rate of 100% in both groups. The mean preoperative GCS score was 13(12.25,15) for study group vs 13(12,14) for control group(P>0.05). GCS score on the day after the operation was improved to 15 for each patient in endoscopic surgery group, while 15(14,15)in the open surgery group (P<0.01). Conclusions Endoscopic subacute subdual hematoma removal through a small bone window achieved a satisfactory hematoma removal with minimally invasive method when compared to open surgery.