What is the role of neurosurgical intervention in acute on chronic subdural hematoma?

From the Guidelines

Neurosurgical intervention is a crucial treatment option for acute on chronic subdural hematoma, with minimally invasive surgery (MIS) being a safe and potentially useful approach to reduce mortality and improve functional outcomes. When considering the role of neurosurgical intervention in acute on chronic subdural hematoma, it is essential to weigh the benefits and risks of different surgical approaches. The 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage from the American Heart Association/American Stroke Association 1 provides valuable insights into the effectiveness of MIS techniques.

Key Considerations

• MIS techniques, such as endoscopic or stereotactic aspiration, with or without thrombolytic use, may be useful in reducing mortality and improving functional outcomes, although the level of evidence for the latter is lower.
• The mortality benefit of MIS compared to craniotomy is uncertain, but MIS may be considered to improve functional outcomes compared to conventional craniotomy.
• Surgeon and center skill and experience are crucial for the success of MIS interventions.

Surgical Approaches

• Burr hole craniostomy, twist-drill craniostomy, or craniotomy are common procedures for surgical evacuation of acute on chronic subdural hematoma.
• Burr hole surgery is often the preferred first-line approach due to its balance of effectiveness and lower invasiveness.
• The procedure involves creating one or two small holes in the skull, evacuating the blood collection, and often placing a temporary drain for 24-48 hours to prevent reaccumulation.

Post-Operative Care

• Close monitoring for complications such as rebleeding, seizures, and infections is essential.
• Anticoagulation management is critical, with medications typically held perioperatively and resumed 1-2 weeks after surgery depending on the patient's thrombotic risk.
• Surgery addresses the immediate mass effect by removing the blood collection, allowing brain re-expansion and resolution of symptoms, while also removing the inflammatory mediators in the hematoma that contribute to its growth through increased capillary permeability.

From the Research

Role of Neurosurgical Intervention in Acute on Chronic Subdural Hematoma

• Neurosurgical intervention plays a crucial role in the management of acute on chronic subdural hematoma, with various surgical techniques available, including burr hole drainage, craniotomy, and twist-drill craniostomy 2.
• The choice of surgical technique depends on the individual patient's condition, with burr hole drainage being a relatively safe technique that can be employed under local anesthesia, making it a suitable option for high-risk surgical candidates 2.
• Studies have compared the efficacy of different surgical techniques, with burr hole drainage showing comparable results to craniotomy in terms of postoperative recurrence rates 3, 4.
• The use of drainage systems, such as subdural or subgaleal drains, has been shown to reduce the risk of recurrence, with the position of the drain not being significant, but early drain removal being associated with higher recurrence rates 2, 4.
• Craniotomy is associated with high morbidity and mortality and should be reserved for recurrent and large septate hematoma cases 2.
• Postoperative care, including head elevation, can help reduce the risk of recurrence 2.
• The role of embolization of the middle meningeal artery (EMMA) as a novel treatment modality is promising, but requires further approval in terms of large sample-sized multicenter randomized control trials 2.
• Surgical techniques, such as mini-craniotomy and burr hole evacuation with subperiosteal drain or subdural drain, have been compared, with multiple burr hole hematoma evacuation with subperiosteal drain placement showing beneficial post-operative outcomes, including low recurrence risk and improved post-operative quality of life 5.