The surgical management of chronic subdural hematoma

Abstract

Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.

Treatment of chronic subdural hematoma: 5-year clinical experience

“…In general, TDC produce the smallest openings of the skull (< 10 mm), while BHC carried out using a high-speed drill enable larger openings (< 30 mm in diameter). Removal of a substantial piece of bone (> 30 mm) that is replaced and fixed to the skull defect following evacuation constitues a craniotomy (7,14,41). Single or double burr-hole craniostomy is the most common procedure for treatment of a patient with CSDH over the last 20 years.…”

Chronic Subdural Haematoma: Systematic Review Highlighting Risk Factors for Recurrent Bleeds

“…1,2 The incidence of CSDH is 8-58 per 100,000 in individuals over 65 years of age. 3 However, with continuous rise of life expectancy together with a widening usage of anti-coagulants and anti-platelets medications worldwide, the incidence of this is likely to continue rising. 4 Clinically, as the name suggests, CSDH does not present acutely and it may remain silent for variable periods of times and may present insidiously or with non-specific features.…”

Management of subdural chronic hematoma in Colombia: national survey

“…Within the medication given to the patient, the anticonvulsants have been routinely used in the post-surgical period, based on the concept that after the intervention, patients may frequently exhibit some extent of the underlying traumatic brain injury, thus establishing a risk factor for seizures. (6) Although the data indicate that 88.9% do not use them, 9.7% use it for 5 to 7 days and 1% use it only in the first hours. Despite this, its use is not yet considered as a routine or standardized practice (14).…”

“…65 years (5,6), being more frequent in the male sex, (7) people with risks of falls, convulsions, alcohol abuse, coagulation disorders (2,8) and associated medicines (9). Its origin begins from the formation of acute hematomas, which may resolve spontaneously or increase in size and continue to enlarge, generating rupture of small veins as it expands, further increasing the amount of blood and thus becoming a HSC8, (10).…”