From the Guidelines
Chronic subdural hematoma management should prioritize treating the underlying cause, such as a spinal CSF leak, and symptomatic haematomas with significant mass effect may require burr hole drainage. The management approach depends on the presence of symptoms and the size of the hematoma. According to the multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension 1, small or asymptomatic haematomas should be managed conservatively while treating the CSF leak.
Key considerations in management include:
- Investigating the possibility of spinal CSF leak in patients with subdural haematoma/hygromas using MRI of the brain with contrast and whole spine, especially in cases with a high index of suspicion such as supportive history of orthostatic headache, or absence of trauma/coagulopathy/alcohol misuse 1
- Treating the underlying cause, such as the spinal CSF leak, as part of the management plan
- Symptomatic haematomas with significant mass effect may need burr hole drainage in conjunction with treating the leak 1
- Conservative management for small or asymptomatic haematomas, which includes close monitoring and treatment of the underlying cause
The goal of management is to alleviate symptoms, prevent further complications, and improve quality of life, while also addressing the underlying cause of the hematoma. By prioritizing the treatment of the underlying cause and using a multidisciplinary approach, patients with chronic subdural hematoma can receive effective management and improve their outcomes.
From the Research
Management of Chronic Subdural Hematoma
The management of chronic subdural hematoma (CSDH) can be divided into surgical and nonsurgical approaches.
- Surgical treatment is the most preferred method, with burr hole (BH) craniostomy and twist drill (TD) craniostomy being the most commonly used techniques 2.
- Nonsurgical treatment, including conservative management, is often successful in asymptomatic patients with small CSDHs 3, 4.
- For symptomatic patients, trephination is the treatment of choice, either by BH or TD, as it offers rapid resolution of symptoms and a short period of hospitalization 2.
- In cases where the risk of recurrence is high, additional management may be necessary, and for refractory CSDHs, obliteration of the subdural space may be required 2.
Conservative Management
Conservative management of CSDH involves observation, corticosteroids, atorvastatin, mannitol, tranexamic acid, and etizolam.
- A systematic review and meta-analysis found that 19.82% of patients required rescue surgery, with varied effects of interventions on the need for rescue surgery 5.
- Subgroup analysis showed that corticosteroids and atorvastatin may have some potential benefit in reducing the failure rate of conservative management 5.
- A survey of neurosurgeons found that 46.2% of respondents sometimes use dexamethasone as monotherapy, and 26.2% estimated dexamethasone to have a high efficacy on CSDH 6.
Factors Influencing Treatment Choice
The choice of treatment for CSDH depends on various factors, including:
- Hematoma volume: smaller hematoma volumes are associated with less additional treatment 4.
- Symptom severity: symptomatic patients are more likely to require surgical treatment 2, 6.
- Patient characteristics: age, comorbidities, and antithrombotic medication use may influence treatment choice 4, 6.
- Neurosurgeon preference: practice variation exists among neurosurgeons in different countries, with some preferring surgical treatment and others conservative management 6.