Chronic subdural hematoma: Pathophysiological basis for treatment

Drapkin, Allan J.

doi:10.3109/02688699108998475

Cited by 105 publications

(75 citation statements)

References 23 publications

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“…A more dynamic pathophysiologic perspective is proposed by Drapkin 6 and supported by the experimental studies performed by Ito et al 14 and Labadie et al 15,16 . In their view, the presence of some products from the erythrocyte lysis inside the subdural space, probably as a consequence of the rupture of some cortical bridge veins, induces a local inflammatory response, and a cycle of bleeding-fibrinolysis where neo-membranes and neo-capillaries are involved; a process that may result in the enlargement of the fluid collection.…”

Section: Pathophysiology Of Chronic Subdural Haematomamentioning

confidence: 84%

“…Minor head trauma a few weeks before presentation is a common antecedent. Slow venous bleeding and the creation of neo-membranes around the subdural clot are some recognized pathogenic features in the development of CSH 6,14,15,16 .…”

Section: Introductionmentioning

confidence: 99%

“…Thus, for adequate evaluation and analysis of outcome, it is appropriate to classify patients according to functional clinical scales such as Markwalder's grading score (MGS) 17 . Nonoperative measures, such as, hypertonic or hyperosmolar solutions and systemic glucocorticoids have been used in CSH with favourable results 6,25,26,30 . Noticeably, the literature concerning these therapies consists of small case series and very few clinical observations [1][2][3]13,22,23,26,27,29,30 .…”

Section: Introductionmentioning

confidence: 99%

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Dexamethasone treatment in chronic subdural haematoma

et al. 2009

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Introduction. Neurosurgeons are familiar with chronic subdural haematoma (CSH), a well-known clinical entity, which is usually treated by some modality of trepanation. Despite the excellent outcomes obtained by surgery, complications may occur, some of which may be potentially severe or fatal. Furthermore, up to 25% recurrence rate is reported. The authors present a novel approach to the management of CSH based on the use of dexamethasone as the treatment of choice in the majority of cases.Patients and methods. Medical records of 122 CSH patients were retrospectively reviewed. At admission, symptomatic patients were classified according to the Markwalder Grading Score (MGS). Those scoring MGS 1-2 were assigned to the Dexamethasone protocol (4mg every 8h, re-evaluation after 48-72h, slow tapering), and those scoring MGS 3-4 were, in general, assigned to the Surgical protocol (single frontal twistdrill drainage to a closed system, without irrigation). Patients were followed in the Outpatient Office with neurological assessment and serial CT scans.Results Discussion. The rationale for the use of dexamethasone in CSH lies in its anti-angiogenic properties over the subdural clot membrane, as it is derived from experimental studies and the very few clinical observations published. Surgical evacuation of CSH is known to achieve excellent results but no well-designed trials compare medical versus surgical therapies. The experience obtained from this series lets us formulate some clinical considerations: dexamethasone is a feasible treatment that positively compares to surgical drain (and avoided two thirds of operations); the natural history of CSH allows a 48-72h dexamethasone trial without putting the patient at risk of irreversible deterioration; eliminates all morbidity related to surgery and recurrences; does not provoke significant morbidity itself; reduces hospital stay; does not preclude ulterior surgical procedures; it is well tolerated and understood by the patient and relatives and it probably reduces costs. The authors propose a protocol that does not intend to substitute surgery but to offer a safe and effective alternative.Conclusion. Data obtained from this large retrospective series suggests that dexamethasone is a feasible and safe option in the management of CSH. In the author's experience dexamethasone was able to cure or improve two thirds of the patients. This fact should be confirmed by others in the future. The true effectiveness of the therapy as compared to surgical treatment could be ideally tested in a prospective randomized trial.KEY WORDS: Chronic subdural haematoma. Dexamethasone. Nonoperative treatment. Glucocorticoids. Tratamiento con dexametasona del hematoma subdural crónico

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Section: Pathophysiology Of Chronic Subdural Haematomamentioning

confidence: 84%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Dexamethasone treatment in chronic subdural haematoma

et al. 2009

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“…The course of chronic subdural hematoma is determined by the balance between plasma effusion and/or rebleeding from the neomembranes and the reabsorption of fluid. 2,4,8) The mean duration of hospitalization at our Neurology Department was 11.1 days for the entire series, shortest in the patients with acute hematomas (8.7 days) and longest in the patients with chronic hematomas (13.7 days). These results may have been influenced by the fact that some patients with acute hematomas were transferred to the Intensive Care Unit for further treatment following surgery and so their mean hospital stay at the Neurosurgery Department was shorter than for the other patients.…”

Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of Operative Treatment of a Series of 100 Patients With Subdural Hematoma

Godlewski

Pawełczyk

et al. 2013

Neurol. Med. Chir.(Tokyo)

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This retrospective study of medical records, surgical protocols, patient observation cards, and imaging files of 100 patients treated for subdural hematoma analyzed the type of hematoma, patient age and sex, operative technique, neurological status, cause of injury, duration of hospital stay, mortality rate, and the number of and reasons for reoperations to determine the effects on treatment outcomes. The time between the head injury and onset of neurological symptoms was analyzed versus the type of hematoma determined from computed tomography (CT) scans. Acute hematomas accounted for 38% of the cases, with subacute hematomas representing 20%, and chronic ones accounting for 42%. In trauma patients, the mean time interval between the injury and onset of neurological symptoms was 0.38 days for acute hematomas, 13.8 days for subacute hematomas, and 23.75 days for chronic hematomas. Repeat surgery was carried out in 26% of the cases. Improvement was obtained in 44% of cases, deterioration in 20%, and no change in neurological status in 36%. Timing of the operations was between 15:00 and 23:00 in 45%, between 23:00 and 7:00 in 33%, and between 7:00 and 15:00 in 22%. The classification of hematomas based on CT presentation corresponds to the classification based on the time elapsed between injury and onset of symptoms, and appears to be appropriate and useful in everyday practice. No preceding injury was identified in 31.6% of acute hematomas, 50% of subacute hematomas, and 61.9% of chronic hematomas. Analysis of reoperations indicates that trepanation may be superior to craniotomy as primary surgery for subacute and chronic hematomas. Subdural hematoma surgeries take place at all times of the day, with most carried out outside the usual working hours.

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“…As the operation using 1 burr hole takes half the time required for a 2 burr hole operation, the present research seeks to make a comparison between these two methods. Although plenty of researches have made a comparison between craniotomy methods (such as mini-craniotomy) and utilization of burr hole in the outcome of patients suffering from CSDH [1,10,13], few researches have focused on patients' outcome difference in using one or multiple burr holes [10]. Allahdini et al [7] have studied the factors that influence the clinical outcome of patients suffering from chronic subdural hematoma following burr hole operation.…”

Section: Discussionmentioning

confidence: 99%

Comparing Clinical Responses to Using One Burr Hole and Two Burr Holes to Treat Chronic Subdural Hematoma

Rafi¹,

Dalvandi²,

Bayat³

et al. 2018

Eurasian J Anal Chem

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The therapeutic strategies currently used to treat chronic subdural hematoma (CSDH) include various methods such as craniotomy and twist drill or utilizing Burr hole. The present research seeks to make a clinical comparison between using one burr hole and two burr holes to treat CSDH. This is a randomized, double-blind clinical trial conducted on 70 patients suffering from CSDH candidated for using burr hole. The participants were divided into two equal groups and underwent treatment with 1 burr hole or 2 burr holes. The primary and secondary outcome variables were compared across the two groups prior to and 48 hours following the operation. A total number of 5 death cases were (7.14%) were reported among patients. 2 patients (5.71%) were in the 1 burr hole group, while 3 (8.57%) were in the 2 burr hole group (P = 0.514). The need for undergoing a secondary operation in the 2 burr holes group (1 case, i.e. 2.85%) was significantly less than what was reported in the other group (6 cases, i.e. 17.14%) (P = 0.012). The mean time of hospitalization (1 burr hole: 4.98, 2 burr holes: 3.1, P = 0.001), the pneumosephalus levels 48 hours following the operation (1 burr hole: 9.38, 2 burr holes: 5.91, P = 0.012) and hematoma levels 48 hours following the operation (1 burr hole: 41.57, 2 burr holes: 30.85, P = 0.0001) in the 2 burr holes group were significantly less than what were reported in the other group. 48 hours after the operation, the hematoma volume (1 burr hole: P= 0.031, 2 burr holes: P= 0.002) in both groups exhibited a significant reduction compared to what was observed before the operation. Using 1 or 2 burr holes are quite useful methods to treat CSDH patients. However, the clinical outcome of those patients in the 2 burr holes group was much more favorable.

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Chronic subdural hematoma: Pathophysiological basis for treatment

Cited by 105 publications

References 23 publications

Dexamethasone treatment in chronic subdural haematoma

Dexamethasone treatment in chronic subdural haematoma

Retrospective Analysis of Operative Treatment of a Series of 100 Patients With Subdural Hematoma

Comparing Clinical Responses to Using One Burr Hole and Two Burr Holes to Treat Chronic Subdural Hematoma

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