Management and Outcomes of Chronic Subdural Hematoma
Burr hole drainage is the preferred first-line surgical treatment for symptomatic chronic subdural hematomas, with placement of a subdural drain significantly reducing recurrence rates and improving functional outcomes. 1, 2
Clinical Presentation 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
Management Approach
Conservative Management
- For stable patients with no significant neurological deficits, conservative management with close monitoring is appropriate 3
- Maintain euvolemia to optimize cerebral perfusion 3
- Dexamethasone therapy shows variable effectiveness depending on hematoma subtype, with better results in hematomas without hyperdense components 4
Surgical Indications
- Surgery is indicated if any of the following develop: neurological deterioration, decreased level of consciousness, or increased intracranial pressure refractory to medical management 3, 1
- The presence of preexisting comorbidities causing disturbed consciousness significantly affects outcomes but should not preclude surgical intervention when indicated 5
Surgical Options
- Burr hole craniostomy is the most common and preferred first-line surgical procedure (89% of cases) 2, 1
- Placement of a subdural drain during surgery significantly reduces recurrence rates and improves functional outcomes 2
- Single burr hole procedures are associated with worse functional outcomes compared to multiple burr holes 2
- Craniotomy should be reserved for cases with acute-on-chronic subdural hematomas with solid components that cannot be adequately drained through burr holes 3, 1
Outcomes and Prognostic Factors
- Overall mortality rate is approximately 2%, with morbidity around 14% 2
- Symptomatic recurrence requiring repeat surgery within 60 days occurs in approximately 9% of patients 2
- Unfavorable functional outcome (modified Rankin Scale score of 4-6) at discharge occurs in about 22% of patients 2
Negative Prognostic Factors
- Failure to insert a drain intraoperatively independently predicts recurrence and unfavorable functional outcome 2
- Increasing patient age significantly predicts unfavorable functional outcomes 2
- Enforced postoperative bed rest is associated with worse functional outcomes 2
- Preexisting comorbidities causing disturbed consciousness (particularly dementia and history of stroke) significantly affect outcomes 5
Emerging Treatment Options
- Middle meningeal artery embolization has shown promise in small case series for treating CSDH, potentially offering a less invasive alternative to surgery, though larger studies are needed to establish efficacy 6
Post-Treatment Management
- Regular neurological assessments (at least every 4 hours initially) 3
- Avoid prolonged bed rest as it is associated with worse outcomes 2
- Duration of drainage for 48 hours appears to be as effective as 96 hours 7
- Monitor for potential complications including cerebral venous thrombosis and progression of mass effect 3
Common Pitfalls and Caveats
- Delaying surgical intervention in symptomatic patients with altered consciousness can lead to neurological deterioration and poorer outcomes 1
- Single burr hole procedures should be avoided when possible as they are associated with worse functional outcomes 2
- Enforced postoperative bed rest should be minimized as it is associated with worse outcomes 2
- Patients with preexisting comorbidities causing disturbed consciousness require closer monitoring as they have higher postoperative morbidity and mortality 5