What is the management of chronic subdural hematoma (CSDH)?

Management of Chronic Subdural Hematoma

Initial Decision: Conservative vs. Surgical Management

For stable, asymptomatic or minimally symptomatic chronic subdural hematoma (CSDH) patients, conservative management with close monitoring is the primary approach, with surgical intervention reserved for neurological deterioration, significant mass effect, or progression on imaging. 1

Assessment Parameters

Establish baseline status by evaluating:

• Glasgow Coma Scale (GCS) score 1
• Pupillary examination 1
• Detailed neurological examination for focal deficits 1
• Symptoms including headache, altered consciousness, and vomiting 1
• Hematoma characteristics on CT: thickness, midline shift, volume, and density pattern 2

Conservative Management Strategy

Patient Selection for Non-Operative Management

Conservative management is appropriate for patients who are:

• Neurologically stable without significant deficits 1
• Asymptomatic or mildly symptomatic 3
• Able to maintain normal daily activities (Karnofsky Performance Scale ≥70) 3

Medical Management Options

Low-dose hydrocortisone (not dexamethasone) is safe and effective for asymptomatic or mildly symptomatic patients who are unsuitable for or decline surgery. 3 Treatment typically continues for an average of 5 months, with significant hematoma volume reductions observed at 2 weeks, 1 month, and 3 months. 3

Avoid dexamethasone as primary therapy in symptomatic patients—it is ineffective and associated with higher morbidity. 2, 4 When dexamethasone was studied, 57% of patients ultimately required surgery, with adjuvant corticosteroid use showing increased complications (RR 1.97). 2, 4

Radiological Considerations for Medical Management

Hematomas without hyperdense components (homogeneous hypodense or isodense) respond better to conservative management than those with hyperdense or mixed-density components. 2 These lesions show larger decreases in thickness (2.2 mm greater reduction) and midline shift (1.3 mm greater reduction) compared to hematomas with hyperdense components. 2

Monitoring Protocol

• Neurological assessments at least every 4 hours initially 1
• Serial CT imaging to assess for progression 1
• Monitor for cerebral venous thrombosis 1
• Maintain euvolemia to optimize cerebral perfusion 1

Surgical Management

Indications for Surgery

Proceed to surgical intervention when:

• Neurological deterioration occurs 1, 4
• Decreased level of consciousness develops 1
• Increased intracranial pressure refractory to medical management 1
• Symptomatic hematomas with significant mass effect 5

First-Line Surgical Approach

Burr hole drainage is the preferred first-line surgical treatment for symptomatic CSDH. 1, 4 A systematic review of 34,829 patients demonstrated that percutaneous bedside twist-drill drainage and operating room burr hole evacuation have equivalent outcomes for mortality (RR 0.69), morbidity (RR 0.45), cure rates (RR 1.05), and recurrence rates (RR 1.0). 4

Place a subdural drain during surgery to reduce recurrence rates (RR 0.46 for recurrence with drain use). 1, 4

Role of Craniotomy

Reserve craniotomy for acute-on-chronic subdural hematomas with solid components that cannot be adequately drained through burr holes. 1 While craniotomy shows higher initial complication rates (RR 1.39) compared to minimally invasive procedures, it is superior for managing recurrences (RR 0.22). 4, 6

Emerging Treatment: Middle Meningeal Artery Embolization

Middle meningeal artery (MMA) embolization is an emerging option for CSDH, though it currently lacks high-quality evidence from randomized controlled trials. 7 This technique may be considered for patients who fail conservative management or have recurrent hematomas, but requires further study to establish efficacy. 7

Special Populations

Advanced age alone should not preclude surgical intervention if clinically indicated. 1 The mean age in successful conservative management series was 78.5 years, and in surgical series was 76 years. 4, 3

Critical Pitfalls to Avoid

• Do not delay surgical intervention when neurological deterioration occurs—this leads to poorer outcomes 1
• Avoid hypervolemia, which does not improve outcomes and may cause complications 1
• Do not use dexamethasone as primary therapy in symptomatic patients—it increases morbidity without improving outcomes 2, 4
• Do not assume all CSDH subtypes respond equally to medical management—hyperdense and mixed-density hematomas have higher failure rates (81% in separated hematomas) 2