Evidence-Based Treatment of Chronic Subdural Hematoma

Abstract

Addi"ional informa"ion is available a" "he end of "he chap"er h""p://dx.doi.org/10.5772/57336 . IntroductionChronic subdural hematoma cSDH is one of the most frequent neurosurgical entities caused by head trauma. Since cSDH affects mainly elderly patients and the population continues to age, it has become a common neurosurgical disease seen by both general and specialized health-care practitioners. Despite the increasing prevalence of cSDH, class I studies, and evidence regarding the management of this disease is lacking. We provide an overview of the epidemiology, pathophysiology and etiology of cSDH and discuss several controversial aspects of its management including indication and timing of surgery, steroid treatment, the effectiveness of anti-epileptic prophylaxis, comparative effectiveness of various techniques for surgical evacuation, the timing of postoperative resumption of anticoagulant medication, and protocols for mobilization following evacuation of cSDH. Complications of surgical evacuation such as recurrent hematoma, postoperative epilepsy, brain injury and/or iatrogenic intracerebral bleeding due to hematoma evacuation, drainage insertion or irrigation, and ways to avoid them are also discussed. "s the incidence of cSDH is expected to increase and most treatment aspects lack clear consensus, further large prospective studies are needed. For this reason, a randomized, prospective study evaluating one aspect of the management of cSDH is currently in progress at our institution.. Definition " chronic subdural hematoma cSDH is defined as chronic ≥ weeks intracranial bleeding between the dura mater which adheres to the skull , and the arachnoid mater which envelops © 2014 Soleman e" al.; licensee InTech. This is a paper dis"rib""ed "nder "he "erms of "he Crea"ive Commons A""rib""ion License (h""p://crea"ivecommons.org/licenses/by/3.0), which permi"s "nres"ric"ed "se, dis"rib""ion, and reprod"c"ion in any medi"m, provided "he original work is properly ci"ed. the brain . The underlying cause of cSDH is usually traumatic tearing of the bridging veins which connect the brain surface with the dura mater.[ ]. . EpidemiologyThe incidence of cSDH is estimated at . -per ' people, rising up to per ' people in patients above the age of [ -]. The average age of patients with cSDH is approximately years old [ ]. "s the population continues to mature, incidence is expected to double by the year [ , ]. " large demographic study found the prevalence of cSDH in patients older than to be significantly higher % vs. % [ ]. In addition, men are more frequently affected than women % vs. % . In % of the cases, the patient has suffered a fall in the past and % of the patients were either treated with oral anticoagulants or platelet aggregation inhibitors. The reported recurrence rates range from . % to % [ -]. The most common risk factors are advanced age, alcohol abuse, seizures, cerebrospinal fluid CSF shunts, coagulopathies, blood thinners, and patients at risk for falling e.g. hemiplegia . In -% of the cases, cSDHs are b...

The number of burr holes and use of a drain do not interfere with surgical results of chronic subdural hematomas

“…Epidemiological profiles were similar to those expected, with the exception of the mean age being greater than usually observed (63 years old) 2,7 . Presenting symptoms were, respectively, motor deficit (39.4%), headache (9.1%) and impairment of consciousness/mental confusion (8.4%), all in agreement with those described in the literature 3,27 .…”

“…Chronic subdural hematoma is one of the most frequent diagnoses in neurosurgery 1,2,3 . It is characterized by an intracranial hemorrhage with a history of trauma in 50% of patients and occurs predominantly in males and in the elderly 7,10,20,21 .…”

“…Chronic subdural hematoma (CSDH) is characterized by a chronic deposition of clot in the subdural space, usually with favorable prognosis 1,2 . It is a frequent neurosurgical condition, commonly associated with a previous history of trauma 3 .…”

“…The main risk factors involved are advanced age, male gender, alcoholism and coagulopathies, including therapeutic anticoagulation and antiplatelet therapy 1,2,6 . Its treatment may be conservative or surgical, depending on symptoms and clot size 3,7 .…”

Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

“…14 Once discontinued, the optimal timing for the postoperative resumption of antiplatelet therapy is not defined. 15 Of course, ASA is typically resumed as soon as possible in patients at risk for major perioperative cardiovascular complication, even though its early postoperative resumption might lead to higher cSDH recurrence rates.…”