SCUBA technique

Free Article from Mosteiro et al. from the Department of Neurosurgery Hospital Clínic of Barcelona and Hospital Germans Trias I Pujol

Stereotactic, Computer-assisted, Ultrasound-guided, Burr hole Aspiration.

It is a Intracerebral hemorrhage minimally invasive surgery.

The SCUBA technique combines real-time ultrasound imaging with stereotactic navigation through a burr hole craniostomy, aiming to maximize hematoma evacuation while minimizing brain trauma.

Stereotactic canula insertion, clot evacuation with aspiration-debriding system under endoscopic view. Step-by-step ultrasound findings are detailed.

ICH endoscopic evacuation may become a workhorse for cerebrovascular surgeons. Ultrasound provides real-time feedback on hematoma evacuation, becoming a reliable dynamic element in intraoperative decision-making. Yet, US requires a different operative setup and adds to the learning curve ¹⁾

The SCUBA technique represents an evolution in the minimally invasive surgical management of intracerebral hemorrhage (ICH). By combining:

Stereotactic navigation (for precise trajectory planning),

Real-time ultrasound (US) guidance (for intraoperative visualization), and

Endoscopic clot aspiration and debridement (via burr-hole craniostomy),

The method seeks to maximize hematoma evacuation while minimizing collateral brain injury.

This multi-modal approach addresses some of the main challenges in ICH surgery: accurate targeting, real-time feedback, and minimal invasiveness.

2. Strengths

✅ Real-time monitoring: Ultrasound offers continuous feedback on hematoma volume and residual clot, supporting dynamic decision-making during surgery.

✅ Multimodal synergy: The fusion of stereotaxy and US ensures accurate cannula placement and permits visual and tactile confirmation during aspiration and debridement, improving safety.

✅ Minimally invasive philosophy: Burr-hole access and the use of endoscopic tools limit parenchymal disruption and potentially reduce post-op morbidity.

✅ Didactic value: The workflow is well-documented, including a step-by-step account of ultrasound findings, which supports reproducibility and teaching.

✅ Scalability:

Although technically demanding, SCUBA is compatible with existing stereotactic and endoscopic infrastructure, making it feasible in high-volume cerebrovascular centers.

3. Limitations and Challenges

❌ Learning curve and setup complexity: The integration of real-time US into the surgical field alters the ergonomic and technical flow of standard ICH evacuation. This may require significant retraining and infrastructure adjustments, especially in institutions unfamiliar with intraoperative US.

❌ Ultrasound limitations: While dynamic, intraoperative US can suffer from limited resolution in deep or calcified areas and may be affected by bone artifacts or hematoma density. Interpretation requires training and experience.

❌ Lack of comparative outcomes: As presented, the technique is more descriptive than evaluative. There is no comparative data against conventional endoscopic evacuation or MISTIE-like catheter-based techniques in terms of:

Hematoma evacuation rate

Functional outcomes

Perioperative complication rates

Operative time

❌ Endoscopic role is under-characterized:

Although endoscopy is used in combination with US, the relative contribution of each modality is not clearly delineated. More granular analysis would help clarify whether US adds incremental value over purely endoscopic evacuation.

4. Potential Impact and Future Directions The SCUBA technique is a promising step forward in the standardization of ICH evacuation, particularly for deep or large-volume hematomas where traditional microsurgical craniotomy is too invasive. If validated in multicenter studies, it may become a “workhorse” technique for cerebrovascular teams, as the authors suggest.

However, its broad adoption will depend on:

Evidence from prospective trials

Standardized training protocols

Cost-effectiveness analyses compared to other minimally invasive strategies

⭐ Conclusion The SCUBA technique exemplifies the shift toward image-guided, precision-based neurovascular surgery. Its innovation lies in integrating stereotaxy, ultrasound, and endoscopy into a coherent, minimally invasive workflow. While it shows clear technical potential, its clinical superiority and scalability remain to be proven through rigorous comparative studies. As such, it should currently be viewed as an advanced technique for specialized centers, rather than a general standard of care.