Subdural Evacuating Port System (SEPS)

see IntegraSubdural Evacuation System.

Twist drill craniostomy (TDC) with closed system drainage and Subdural Evacuating Port System is an effective treatment option for chronic subdural hematoma (CSDH).

In a radiological study, all the branches of the middle meningeal artery ran posterior to the coronal suture and the vascular grooves were also located posterior to the coronal suture at the level of the superior temporal line (STL). The average distance of the vascular grooves was 8.0 +/-5.8 mm. Thirty-five procedures were performed. The coronal suture and the STL could be identified clearly on brain CT scans. The mean thickness of the skull and the CSDH at the proposed point was 8 mm (range 5-13 mm) and 20 mm (range 10-28 mm), respectively. All the TDCs except 1 were congruent with the preoperative brain CT scans. One CSDH recurred 1 month after the first operation and was revised using the same procedure. No other complications occurred.

One centimeter anterior to the coronal suture at the level of the STL is suitable as the normal entry point of the TDC for symptomatic CSDH. The thickness of the CSDH can be measured at this point on a preoperative brain CT scan. Furthermore, the entry point on the scalp can be accurately estimated using surface landmarks 1).

The insertion of a subdural drain was associated with a statistically significant reduction in the risk of symptomatic recurrence and the requirement for further surgical intervention of chronic subdural hematoma after surgical evacuation. Furthermore, it was associated with statistically significant improvements in both short-term and long-term functional outcome 2).

The Subdural Evacuating Port System (SEPS) is a subdural drain that permits the neurosurgeon to drain subacute or chronic subdural hematoma by a method which is minimally invasive, simple and safe to the standard procedure of burr-hole evacuation 3) 4) 5) 6).

The appearance of the winged canula positioned with its tip in the diploic space overlying the subdural space should allow the radiologist to identify it correctly 7).

Because chronic SDH frequently occurs in elderly patients with multiple comorbidities, the bedside approach afforded by the subdural evacuating port system (SEPS) is an attractive alternative method that is performed under local anesthesia and conscious sedation.

A prospectively maintained database of 23 chronic SDHs treated by bur hole or craniotomy and of 23 chronic SDHs treated by SEPS drainage at Tufts Medical Center was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcome was collected. The volume of SDH before and after treatment was semiautomatically measured using imaging software.

There was no significant difference in initial SDH volume (94.5 cm(3) vs 112.6 cm(3), respectively; p = 0.25) or final SDH volume (31.9 cm(3) vs 28.2 cm(3), respectively; p = 0.65) between SEPS drainage and traditional methods. In addition, there was no difference in mortality (4.3% vs 9.1%, respectively; p = 0.61), length of stay (11 days vs 9.1 days, respectively; p = 0.48), or stability of subdural evacuation (94.1% vs 83.3%, respectively; p = 0.60) for the SEPS and traditional groups at an average follow-up of 12 and 15 weeks, respectively. Only 2 of 23 SDHs treated by SEPS required further treatment by bur hole or craniotomy due to inadequate evacuation of subdural blood.

This results means thats a safe and effective alternative to traditional methods of evacuation of chronic SDHs and should be considered in patients presenting with a symptomatic chronic SDH 8).

The SEPS is relatively simple to use and may be especially useful to emergency department staff in outlying areas where there is a shortage of neurosurgical coverage 9).

This technique should be added to the armament of treatment options for a neurosurgeon to treat or temporize a hyperacute SDH with increased intracranial pressure in specific patients 10).

Despite decreasing length of stay LOSs as treatment for cSDH evolved from burr holes BHs to SEPS, the LOS for a cSDH is still longer than that of a patient undergoing craniotomy for brain tumor 11).

The efficacy and safety of SEPS is similar to that of other twist-drill methods reported in the literature. The efficacy of this treatment as measured by radiographic worsening or the need for a subsequent procedure is statistically similar to that of bur hole treatment. There was no difference in mortality or other adverse outcomes associated with SEPS 12).

Specifically, hypodense subdural collections drain more effectively through an SEPS than do mixed density collections. Although significant bleeding after SEPS insertion was uncommon, 1 patient required urgent surgical hematoma evacuation due to iatrogenic injury 13).

The SEPS a first-line treatment for the majority of patients with cSDH, management of cSDH must be tailored to each patient. In mixed density collections with large proportions of acute hemorrhage and in collections with numerous intrahematomal septations, alternative surgical techniques should be considered as first-line therapies 14).

Carpenter et al. evaluated the experience with middle meningeal artery embolization (MMA) combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with chronic subdural hematoma (cSDH). A single-institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization, and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have a shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for chronic subdural hematoma patients with significant comorbidities who are poor surgical candidates 15).

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Alcalá-Cerra G, Young AM, Moscote-Salazar LR, Paternina-Caicedo A. Efficacy and safety of subdural drains after burr-hole evacuation of chronic subdural hematomas: systematic review and meta-analysis of randomized controlled trials. World Neurosurg. 2014 Dec;82(6):1148-57. doi: 10.1016/j.wneu.2014.08.012. Epub 2014 Aug 10. Review. PubMed PMID: 25118059.
Asfora WT, Schwebach L, Louw D. A modified technique to treat subdural hematomas: the subdural evacuating port system. S D J Med. 2001 Dec;54(12):495-8. PubMed PMID: 11775490.
Asfora WT, Schwebach L. A modified technique to treat chronic and subacute subdural hematoma: technical note. Surg Neurol. 2003 Apr;59(4):329-32; discussion 332. PubMed PMID: 12748020.
Scotton WJ, Kolias AG, Ban VS, Crick SJ, Sinha R, Gardner A, Massey K, Minett T, Santarius T, Hutchinson PJ. Community consultation in emergency neurosurgical research: lessons from a proposed trial for patients with chronic subdural haematomas. Br J Neurosurg. 2013 Oct;27(5):590-4. doi:10.3109/02688697.2013.793291. Epub 2013 Jun 14. PubMed PMID: 23767683.
Singla A, Jacobsen WP, Yusupov IR, Carter DA. Subdural evacuating port system (SEPS)–minimally invasive approach to the management of chronic/subacute subdural hematomas. Clin Neurol Neurosurg. 2013 Apr;115(4):425-31. doi: 10.1016/j.clineuro.2012.06.005. Epub 2012 Jul 3. PubMed PMID: 22763191.
Lollis SS, Wolak ML, Mamourian AC. Imaging characteristics of the subdural evacuating port system, a new bedside therapy for subacute/chronic subdural hematoma. AJNR Am J Neuroradiol. 2006 Jan;27(1):74-5. PubMed PMID: 16418360.
Safain M, Roguski M, Antoniou A, Schirmer CM, Malek AM, Riesenburger R. A single center's experience with the bedside subdural evacuating port system: a useful alternative to traditional methods for chronic subdural hematoma evacuation. J Neurosurg. 2013 Mar;118(3):694-700. doi: 10.3171/2012.11.JNS12689. Epub 2012 Dec 21. Erratum in: J Neurosurg. 2013 Jul;119(1):256. Schirmer, Clemens S [corrected to Schirmer, Clemens M]. PubMed PMID: 23259822.
Asfora WT, Klapper HB. Case report: treatment of subdural hematoma in the emergency department utilizing the subdural evacuating port system. S D Med. 2013 Aug;66(8):319-21. PubMed PMID: 24175497.
Ivan ME, Nathan JK, Manley GT, Huang MC. Placement of a subdural evacuating port system for management of iatrogenic hyperacute subdural hemorrhage following intracranial monitor placement. J Clin Neurosci. 2013 Dec;20(12):1767-70. doi: 10.1016/j.jocn.2013.03.009. Epub 2013 Oct 3. PubMed PMID: 24090520.
Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013 Apr;35(3):233-42. doi: 10.1179/1743132813Y.0000000166. Review. PubMed PMID: 23485050.
Rughani AI, Lin C, Dumont TM, Penar PL, Horgan MA, Tranmer BI. A case-comparison study of the subdural evacuating port system in treating chronic subdural hematomas. J Neurosurg. 2010 Sep;113(3):609-14. doi: 10.3171/2009.11.JNS091244. PubMed PMID: 20001585.
Kenning TJ, Dalfino JC, German JW, Drazin D, Adamo MA. Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. J Neurosurg. 2010 Nov;113(5):1004-10. doi: 10.3171/2010.5.JNS1083. Epub 2010 May 28. PubMed PMID: 20509728.
Neal MT, Hsu W, Urban JE, Angelo NM, Sweasey TA, Branch CL Jr. The subdural evacuation port system: outcomes from a single institution experience and predictors of success. Clin Neurol Neurosurg. 2013 Jun;115(6):658-64. doi: 10.1016/j.clineuro.2012.07.017. Epub 2012 Aug 3. PubMed PMID: 22863544.
Carpenter A, Rock M, Dowlati E, Miller C, Mai JC, Liu AH, Armonda RA, Felbaum DR. Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurg Rev. 2021 Apr 24. doi: 10.1007/s10143-021-01553-x. Epub ahead of print. PMID: 33893872.
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