Twist-drill craniostomy with pressure-controlled fibrinolytic irrigation therapy for the evacuation of bilateral acute traumatic subdural hematoma: illustrative case.

backgroundBilateral acute subdural hematomas (aSDHs) present a significant challenge for neurosurgeons, particularly due to the risk of contralateral hematoma enlargement following unilateral evacuation and subsequent volume shifts. This complexity is further compounded in elderly patients with preexisting health conditions. OBSERVATIONS: This case report presents a novel minimally invasive approach for managing bilateral aSDHs in a 76-year-old female. The patient developed bilateral aSDHs following head trauma and was considered high risk for general anesthesia and bilateral craniotomies. A minimally invasive technique was utilized, involving twist-drill craniostomy under local anesthesia combined with pressure-controlled fibrinolytic therapy using the IRRAflow and LiquoGuard 7 systems. The patient was treated with continuous pressure-controlled irrigation therapy using an electrolyte solution containing 200,000 IU/l of urokinase infused at a rate of 100 ml/hr. The patient showed significant improvement, with complete resolution of the hematomas and no residual neurological deficits. LESSONS: This case demonstrates the effectiveness of minimally invasive techniques that avoid the risks associated with general anesthesia and craniotomies. While these findings are promising, they should be interpreted with caution and require prospective confirmation in a larger cohort of patients. Nonetheless, they align with the recent literature that supports minimally invasive approaches for aSDHs. https://thejns.org/doi/10.3171/CASE24577.