Treatment of Chronic Subdural Hematoma (CSDH)
For symptomatic CSDH with significant mass effect or neurological deterioration, immediate burr hole drainage with subdural drain placement is the definitive treatment, while small or asymptomatic hematomas should be managed conservatively with close monitoring. 1
Surgical Indications
Proceed immediately to surgical evacuation when any of the following are present: 1
- Decreased level of consciousness or neurological deterioration
- Significant mass effect on imaging
- Progressive symptoms despite conservative management
- Glasgow Coma Scale (GCS) score decline, particularly motor response deterioration 1
Burr hole drainage is the preferred first-line surgical technique, with subdural drain placement to reduce recurrence rates. 1 Double burr hole is the most commonly utilized approach among neurosurgeons worldwide. 2
Conservative Management Strategy
Conservative management is appropriate for: 1, 3
- Asymptomatic or minimally symptomatic patients (Markwalder score 0-1)
- Small hematomas without significant mass effect
- Patients with mild to moderate headache without neurological deficits
Key components of conservative management include: 1, 3
- Regular neurological assessments with serial imaging to monitor for progression
- Maintaining euvolemia (avoid hypervolemia as it does not improve outcomes) 1
- Close observation with "wait and watch" approach 4
Important caveat: Conservative management fails in approximately 20% of patients, requiring rescue surgery. 5 Hematomas with volume >60 mL or midline shift >6 mm have higher failure rates. 3
Pharmacological Adjuncts
While surgery remains first-line, certain medications may be considered as adjunct therapy in selected cases:
Corticosteroids (Dexamethasone): May reduce the need for rescue surgery (risk ratio 0.30) in symptomatic patients who are not worsening, though use with caution given side effects. 4, 5 Only 26% of neurosurgeons consider dexamethasone highly effective. 2
Atorvastatin: Shows promise in reducing failure rates (risk ratio 0.16) and appears safe for asymptomatic or mildly symptomatic patients. 4, 5
Tranexamic acid: May be effective as adjunct to surgery, but risk of thromboembolic events in patients on anticoagulation is unclear. 4, 5
Special Consideration: CSDH Associated with Spontaneous Intracranial Hypotension
If subdural hematoma occurs without clear trauma history or in the context of orthostatic headache, perform MRI of brain with contrast and whole spine to investigate for spinal CSF leak. 6, 1
- Small or asymptomatic hematomas: Manage conservatively while treating the underlying CSF leak 6, 1
- Symptomatic hematomas with significant mass effect: Burr hole drainage in conjunction with treating the leak 6, 1
Anticoagulation Management
Rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K for patients on anticoagulation who develop CSDH. 1 Anticoagulation interruption typically lasts 7-15 days, with low risk of ischemic events during this period. 1
Post-Operative Care
- Routine CT scan at 24 hours post-surgery is standard practice among 69% of neurosurgeons 2
- Antiepileptic drugs are NOT recommended for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes 1
- Consider restarting anticoagulation approximately 4 weeks after surgical removal if no ongoing fall risk 1
Critical Pitfalls to Avoid
Do not delay surgical intervention when neurological deterioration occurs, as this leads to poorer outcomes. 1 The presence of abnormal pupils indicates herniation risk and requires urgent action. 1
Do not assume all CSDH will resolve spontaneously - there are no clear clinical or radiological signs predicting spontaneous resolution, and 19-20% of conservatively managed patients ultimately require surgery. 4, 5
Avoid hypervolemia, as it does not improve outcomes and may cause complications. 1