What treatment options are available for an 87-year-old male with a chronic subdural hematoma (CSDH) in the left parietal region, who has undergone two burr hole craniostomies (BHC) but still presents with symptoms at 6 weeks and is experiencing sundowners syndrome?

Management of Chronic Subdural Hematoma in an 87-Year-Old Male with Sundowning Syndrome

For an 87-year-old male with persistent left parietal chronic subdural hematoma (CSDH) after two burr hole craniostomies (BHC) and sundowning syndrome, a subdural peritoneal shunt placement is the recommended treatment option to prevent further recurrence and improve neurological outcomes.

Evaluation of Current Status

• Persistent CSDH after two BHCs indicates treatment resistance, requiring escalation beyond standard evacuation procedures 1
• Sundowning syndrome (evening confusion/agitation) suggests neurological impact from the persistent CSDH, which may worsen cognitive function if left untreated 1
• Advanced age (87 years) is an important factor in decision-making but should not preclude appropriate surgical intervention when indicated 2

Treatment Options for Recurrent CSDH

Subdural Peritoneal Shunt

• Placement of a subdural peritoneal shunt is highly effective for recurrent CSDH cases that have failed multiple burr hole evacuations 3
• This approach provides continuous drainage of the subdural collection, reducing the recurrence rate and the risk of brain re-injury 3
• Particularly beneficial in elderly patients where brain re-expansion is often poor due to cerebral atrophy 4

Craniotomy with Membranectomy

• Reserved for cases with thick membranes or multiloculated collections that cannot be adequately drained through burr holes 1
• Higher surgical risk in elderly patients, with increased risk of stroke and longer hospital stays in patients >80 years 5
• Should be considered if imaging shows significant membrane formation preventing adequate drainage 5

Medical Management Options

• Corticosteroids may be considered as an adjunctive therapy to reduce inflammation and promote resolution 6
• Maintain euvolemia to optimize cerebral perfusion while avoiding hypervolemia 2
• Consider treating underlying spontaneous intracranial hypotension if suspected as a cause of recurrence 7, 8

Management Algorithm

1. Imaging Assessment:

   • Obtain MRI of the brain with contrast to evaluate for:
     • Thickness and organization of membranes 9
     • Possible underlying spontaneous intracranial hypotension 8
     • Multi-loculation of the hematoma 6

2. Surgical Intervention:

   • Primary Recommendation: Subdural peritoneal shunt placement 3
   • Benefits include:
     • Continuous drainage of subdural fluid
     • Lower recurrence rates compared to repeated burr hole evacuations
     • Less invasive than craniotomy
     • Particularly effective in elderly patients with poor brain re-expansion 4

3. Post-Operative Management:

   • Regular neurological assessments (at least every 4 hours initially) 2
   • Maintain euvolemia 1
   • Consider thromboprophylaxis 7
   • Monitor for potential complications including seizures and cerebral venous thrombosis 1, 7

4. Management of Sundowning:

   • Maintain consistent sleep-wake cycle 7
   • Consider methylphenidate for attention or modafinil for wakefulness if needed 7
   • Avoid sedatives when possible as they may worsen confusion 7

Special Considerations for Elderly Patients

• Poor brain re-expansion is common in elderly patients (>80 years), with re-expansion rates of approximately 45-55% after surgery 4
• Factors associated with poor brain re-expansion include advanced age, pre-existing cerebral infarction, and persistence of subdural air after surgery 4
• Mortality rates in elderly patients with CSDH are approximately 1.2%, with good recovery in about 89% of cases 4

Pitfalls and Caveats

• Delaying appropriate surgical intervention can lead to neurological deterioration and poorer outcomes 2
• Repeated burr hole evacuations without addressing the underlying cause of recurrence may lead to further neurological decline 9
• Careful hemostasis during surgery and complete replacement of subdural hematoma by normal saline to prevent influx of air into the subdural space will improve surgical outcomes 4
• Consider evaluation for underlying spontaneous intracranial hypotension in cases of recurrent subdural collections 7, 8