The conservative and pharmacological management of chronic subdural haematoma: a systematic review

Abstract

Chronic subdural haematoma (cSDH), one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year 2030, owing to the continuous aging of the population. Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations. We provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0–1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, our knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH.

Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review

“…Our conclusion is consistent with that of a recent meta-analysis of 6 studies comprising 756 patients with CSDH, which also suggested that ATO could improve prognosis and neurological recovery (He et al, 2021). Additionally, some studies even suggest that ATO is as effective as surgery in patients with mild CSDH (Shofty and Grossman, 2016;Soleman et al, 2017). Currently, low-dose ATO has been used by many neurosurgeons to promote CSDH absorption and prevent the recurrence of CSDH (Wang et al, 2014;Chan et al, 2017;Tang et al, 2018).…”

National survey on the current practice and attitudes toward the management of chronic subdural hematoma

“…The findings in the cases suggest BHC is the most widely used and most accepted treatment option in symptomatic CSDH, which is in line with up-to-date literature (Kolias et al, 2014;Soleman et al, 2017).…”

Using Local Anesthesia for Burr Hole Surgery of Chronic Subdural Hematoma Reduces Postoperative Complications, Length of Stay, and Hospitalization Cost: A Retrospective Cohort Study From a Single Center

“…Chronic subdural hematoma (CSDH) is a common neurosurgical disease, and the increase is shown as the population aging nowadays. Studies have predicted that CSDH will become the most common brain disease among adults by 2030 (1,2). When individuals with CSDH develop evident clinical symptoms, conservative therapy is relatively ineffective and surgery is often the only option (3).…”