What are the treatment options for chronic subdural hematoma?

Treatment Options and Outcomes for Chronic Subdural Hematoma

Burr hole evacuation is the first-line treatment for symptomatic chronic subdural hematomas, with a recurrence rate of approximately 10-20% requiring reoperation. 1

Surgical Management Options

Surgical evacuation remains the mainstay of treatment for symptomatic chronic subdural hematomas (CSDH) or those exerting significant mass effect. The available surgical approaches include:

1. Burr Hole Craniostomy

   • Most widely practiced technique worldwide
   • Can be performed under:
     • Local anesthesia (LA): Associated with fewer complications (p<0.001), shorter surgery duration (p<0.001), and shorter hospital stays (p<0.001) compared to general anesthesia 2
     • General anesthesia (GA): May be preferred for agitated patients or complex cases

2. Craniotomy

   • Reserved for recurrent cases or those with thick membranes
   • May be necessary when burr hole evacuation fails

3. Twist Drill Craniostomy

   • Less invasive alternative
   • Suitable for selected cases

Factors Affecting Surgical Outcomes

Risk Factors for Recurrence (10-20% of cases)

• Patient-related factors:

  • Alcoholism
  • Seizure disorders
  • Coagulopathy
  • Use of anticoagulants or antiplatelet medications
  • History of ventriculoperitoneal shunt 3

• Radiologic factors:

  • Poor brain re-expansion postoperatively
  • Significant subdural air
  • Greater midline shift
  • Heterogeneous or multi-loculated hematomas
  • Higher-density hematomas 3

• Surgical factors:

  • Lack of or poor postoperative drainage 3

Improving Surgical Outcomes

• Use of subdural drains: Most recent trials favor the use of drains to reduce recurrence rates 4
• Dural biopsy: Should be considered in cases of recurrence or thick outer membrane to rule out underlying pathology 4

Emerging Treatment Modalities

1. Middle Meningeal Artery (MMA) Embolization:

   • Targets the source of recurrent microbleeds
   • Can be used alone or in combination with surgical evacuation
   • Shows promising results with reduced recurrence rates
   • Complete hematoma resolution observed in patients treated with MMA embolization alone
   • Particularly beneficial for patients on antiplatelet/anticoagulant medications 5

2. Pharmacological Management:

   • Steroids: May reduce postoperative recurrence or potentially replace surgery in selected cases
   • Angiotensin-converting enzyme inhibitors: May play a role in management 4

Management Algorithm for CSDH

1. For symptomatic CSDH with significant mass effect:

   • First-line: Burr hole evacuation with postoperative closed-system drainage
   • Consider local anesthesia when feasible (fewer complications, shorter hospital stay)

2. For recurrent CSDH:

   • Consider repeat burr hole evacuation
   • Consider craniotomy for multi-loculated or organized hematomas
   • Consider MMA embolization as adjunctive therapy, especially in patients on anticoagulants

3. For asymptomatic CSDH or high surgical risk patients:

   • Conservative management with close monitoring
   • Consider pharmacological therapy (steroids)
   • Consider MMA embolization as a minimally invasive alternative

Clinical Pitfalls and Considerations

1. Anticoagulation management:

   • Reversal of anticoagulation may be necessary before surgery
   • Timing of anticoagulation resumption is critical to balance thrombotic and hemorrhagic risks

2. Postoperative monitoring:

   • Watch for pneumocephalus, seizures, and recurrence
   • Ensure adequate brain re-expansion

3. Underlying causes:

   • Investigate for coagulation disorders, intracranial hypotension, or dural diseases in cases without clear trauma history 4

4. Elderly patients:

   • Consider comorbidities and frailty in surgical decision-making
   • Local anesthesia may be particularly beneficial in this population

The management of CSDH continues to evolve with new techniques that combine minimally invasive approaches with clinical efficacy. The selection of treatment strategy should be based on patient characteristics, hematoma features, and available expertise to optimize outcomes.