Triple-modality management of complex septated chronic subdural hematoma: a preliminary technical note on feasibility and safety

Background Complex septated chronic subdural hematomas (CSDHs) carry a high risk of recurrence following conventional drainage. This is hypothesized to be driven by three factors: neoangiogenesis, mechanical sequestration by fibrous septa, and a localized inflammatory microenvironment. Objective To introduce and evaluate the preliminary safety and feasibility of a “Triple-Modality” surgical strategy addressing these components. Methods We retrospectively reviewed 7 consecutive patients with complex, trabecular-type CSDHs who underwent a unified, single-session protocol: (1) Middle meningeal artery (MMA) embolization; (2) Neuroendoscopic fenestration; and (3) Intraoperative and postoperative subdural irrigation with a dexamethasone-saline solution (10 mg/500 mL). Outcomes were compared to an exploratory historical cohort of 11 similar patients treated with conventional burr-hole drainage. Results The protocol was successfully applied to all 7 patients (median age 71 years). The median radiographic hematoma volume reduction was >95%. Over a median follow-up of 6.5 months, all patients improved to a Markwalder Grade of 0–1, with no recurrences (0/7, 0%). By contrast, the historical control cohort experienced a 36.3% (4/11) recurrence rate ( p = 0.106). There were no steroid-related systemic complications, subdural empyemas, or wound healing defects observed in the experimental cohort. Conclusion This preliminary technical note demonstrates that combining MMA embolization, endoscopic fenestration, and localized dexamethasone irrigation is technically feasible and safe. While early results suggest excellent radiographic clearance and low recurrence in highly complex CSDHs, larger prospective cohorts are necessary to evaluate the independent efficacy of each modality.