What is the recommended treatment for a patient with a chronic subdural hematoma (SDH) presenting with vomiting, tiredness, and altered consciousness level after a 2-month history of head trauma?

Management of Chronic Subdural Hematoma with Altered Consciousness

For a patient with chronic subdural hematoma presenting with vomiting, tiredness, and altered consciousness level after a 2-month history of head trauma, burr hole evacuation is the recommended first-line surgical treatment.

Clinical Assessment and Diagnosis

• Chronic subdural hematoma (cSDH) typically develops over weeks to months following head trauma, with symptoms including headache, altered consciousness, vomiting, and neurological deficits 1
• CT scan is the primary diagnostic tool to confirm subdural hematoma, assess its size, location, and mass effect 1
• Severity assessment should include Glasgow Coma Scale (GCS), pupillary examination, and evaluation of neurological deficits 1

Treatment Options

Burr Hole Evacuation (Recommended First-Line)

• Burr hole drainage is the preferred first-line surgical treatment for symptomatic chronic subdural hematomas presenting with altered consciousness, vomiting, and tiredness 1
• This minimally invasive procedure effectively evacuates the hematoma while minimizing surgical risks in patients with chronic collections 2
• Local anesthesia may be preferred over general anesthesia for burr hole evacuation as it is associated with:
  • Decreased risk of complications
  • Shorter surgery duration
  • Shorter hospital stay 3

Craniotomy

• Craniotomy should be reserved for cases with:
  • Recurrent hematomas after burr hole drainage
  • Multiloculated hematomas with significant membranes
  • Acute-on-chronic subdural hematomas with solid components 1
• The proportion of primary decompressive craniectomies (versus craniotomies) varies significantly between centers (6-67%), indicating lack of standardization 1

Serial CT Monitoring

• Serial CT monitoring alone without surgical intervention is insufficient for patients presenting with altered consciousness level, vomiting, and tiredness 1
• This approach should be limited to asymptomatic or minimally symptomatic patients with small hematomas 2

Post-Operative Management

• Maintain euvolemia and avoid hypovolemia to optimize cerebral perfusion 1
• Consider subdural drain placement during surgery to reduce recurrence rates 1
• Monitor for complications including:
  • Recurrence (occurs in approximately 4.5% of cases after surgical evacuation with prophylactic middle meningeal artery embolization) 4
  • Pneumocephalus
  • Seizures
  • Infection 3

Adjunctive Therapies

• Middle meningeal artery embolization (MMAE) may be considered as an adjunctive therapy to reduce recurrence rates:
  • Can be performed perioperatively after surgical evacuation
  • Has shown promise in reducing recurrence rates to as low as 4.5% (compared to historical rates of 2-37%) 4, 5
  • MMA remains relatively patent after burr hole evacuation, making subsequent embolization feasible 6

Treatment Algorithm

1. Confirm diagnosis with CT scan
2. For symptomatic patients with altered consciousness, vomiting, and tiredness:
   • Proceed with burr hole evacuation as first-line treatment 1, 2
3. Reserve craniotomy for:
   • Recurrent hematomas
   • Multiloculated collections
   • Acute-on-chronic hematomas with solid components 1
4. Consider adjunctive MMAE to prevent recurrence 4, 5
5. Monitor with follow-up imaging to assess resolution 4

Pitfalls and Caveats

• Delaying surgical intervention in symptomatic patients with altered consciousness can lead to neurological deterioration and poorer outcomes 1
• Recurrence rates after surgical evacuation alone remain significant (2-37%) 5
• Patients on anticoagulants or antiplatelet therapy require special consideration regarding reversal of these medications prior to surgical intervention 1
• Avoid hypervolemia in the postoperative period as it does not improve outcomes and may lead to complications 1