Management of Chronic Subdural Hematoma
Initial Decision: Surgery vs. Conservative Management
For chronic subdural hematoma, burr hole drainage is the preferred first-line surgical treatment when patients have significant mass effect, neurological deterioration, or decreased level of consciousness, while stable patients without significant neurological deficits should be managed conservatively with close monitoring. 1, 2
Indications for Immediate Surgical Evacuation
Proceed directly to surgery if ANY of the following are present:
- Symptomatic hematoma with significant mass effect 1
- Neurological deterioration (declining GCS, new focal deficits) 1, 2
- Decreased level of consciousness 1
- Increased intracranial pressure refractory to medical management 2
Indications for Conservative Management
Conservative management is appropriate when ALL of the following are met:
- No significant neurological deficits 1, 2
- Stable clinical status 2
- Small or asymptomatic hematomas 1
- Patient can be monitored closely 1
Research supports this approach: 81.3% of conservatively managed chronic subdural hematomas resolved spontaneously without intervention in patients without symptoms or with only mild-to-moderate headache 3. Mean hematoma volume in successfully conservatively managed cases was 43.1 mL with mean midline shift of 5.3 mm 3.
Surgical Technique Selection
First-Line Surgical Approach
Burr hole drainage with subdural drain placement is the preferred initial surgical technique 1, 2. A systematic review of 34,829 patients found no significant difference in mortality, morbidity, cure, or recurrence rates between percutaneous bedside twist-drill drainage and operating room burr hole evacuation 4.
When to Consider Craniotomy
Reserve craniotomy for:
- Acute-on-chronic subdural hematomas with solid components that cannot be adequately drained through burr holes 2
- Recurrent hematomas after failed minimally invasive procedures (craniotomy reduces recurrence risk: RR 0.22,95% CI 0.05-0.85) 4
Critical pitfall: Initial craniotomy is associated with higher complication rates (RR 1.39,95% CI 1.04-1.74) compared to burr hole drainage 4.
Adjunctive Surgical Measures
Place a subdural drain during surgery to reduce recurrence rates (RR 0.46,95% CI 0.27-0.76) 4.
Conservative Management Protocol
Monitoring Requirements
- Regular neurological assessments at least every 4 hours initially 2
- Serial CT imaging to monitor for progression 1
- Assess GCS, pupillary examination, and focal neurological deficits 1, 2
- Monitor for headache, altered consciousness, vomiting, and progressive symptoms 1
Medical Management
- Maintain euvolemia to optimize cerebral perfusion 1, 2
- Avoid hypervolemia as it does not improve outcomes and may cause complications 1, 2
- Maintain normothermia, eucarbia, and euglycemia 5
Role of Corticosteroids
Do NOT routinely use dexamethasone as monotherapy for chronic subdural hematoma. While 46.2% of neurosurgeons sometimes use it, adjuvant corticosteroid use is associated with higher morbidity (RR 1.97,95% CI 1.54-2.45) without significant improvement in recurrence or cure rates 6, 4.
Anticoagulation Management
Reversal Strategy
Rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K for patients on anticoagulation who develop subdural hematoma 1.
Resumption of Anticoagulation
Hold anticoagulation for 7-15 days after diagnosis, with low risk of ischemic events during this period 1. For surgically treated traumatic subdural hematomas, restart anticoagulation approximately 4 weeks after surgical removal if no ongoing fall risk or alcohol abuse is present 1.
Post-Operative Management
Imaging
Obtain routine CT scan one day after surgery (69.3% of neurosurgeons follow this protocol) 6.
Seizure Prophylaxis
Do NOT routinely administer antiepileptic drugs for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes 1. Consider antiepileptic drugs only if specific risk factors are present, such as prior epilepsy 1.
ICU-Level Care
Post-operative patients require ICU monitoring with focus on:
- Management of intracranial hypertension (maintain ICP <22 mmHg, CPP >60 mmHg) 5
- Early initiation of enteral feeding, mobilization, and physical therapy 5
Special Consideration: Spontaneous Intracranial Hypotension
If chronic subdural hematoma occurs without clear trauma history, perform MRI of brain with contrast and whole spine to investigate for spinal CSF leak 1, 2. In this context:
- Small or asymptomatic hematomas: manage conservatively while treating the CSF leak 1
- Symptomatic hematomas with significant mass effect: may need burr hole drainage in conjunction with treating the leak 1
Critical Pitfalls to Avoid
- Never delay surgical intervention when neurological deterioration occurs, as this leads to poorer outcomes 1, 2
- Do not use hypervolemia in management 1, 2
- Avoid routine corticosteroid use due to increased morbidity without benefit 4
- Do not perform initial craniotomy unless solid components preclude burr hole drainage 2, 4