Chronic Subdural Hematoma

Abstract

Background: Chronic subdural hematoma (cSDH) is typically a disease that affects the elderly. Neurosurgical evacuation is generally indicated for hematomas that are wider than the thickness of the skull. The available guidelines do not address the common clinical issue of the proper management of antithrombotic drugs that the patient has been taking up to the time of diagnosis of the cSDH. Whether antithrombotic treatment should be stopped or continued depends on whether the concern about spontaneous or postoperative intracranial bleeding, and a presumably higher rate of progression or recurrence, with continued medication outweighs the concern about a possibly higher rate of thrombotic complications if it is stopped.

Methods: In this article, we review publications from January 2015 to October 2020 addressing the issue of the management of antithrombotics in patients with cSDH that were retrieved by a selective search in the Pubmed and EMBASE databases, and we present the findings of a cohort study of 395 patients who underwent surgery for cSDH consecutively between October 2014 and December 2019.

Results: The findings published in the literature are difficult to summarize concisely because of the heterogeneity of study designs. Among the seven studies in which a group of patients on antithrombotics was compared with a control group, four revealed significant differences with respect to the risk of thromboembolic complications depending on previous antithrombotic use and the duration of discontinuation, while three others did not. In our own cohort, discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) was associated with thrombotic complications in 9.1% of patients.

Conclusion: These findings imply that the management of antithrombotics should be dealt with critically on an individual basis. In patients with cSDH who are at elevated risk, an early restart of antithrombotic treatment or even an operation under continued antithrombotic therapy should be considered.

Figure 1

An 89-year-old woman who fell at home. a) Computerized tomography (CT) of the head one day after the fall reveals a thin acute subdural hematoma (aSDH) over the right cerebral hemisphere. Because of the lack of mass effect and the absence neurologic symptoms, surgery was initially not indicated. b) Over the ensuing 5 weeks, the patient became increasingly disoriented and her level of wakefulness was impaired. A new CT revealed a chronic subdural hematoma (cSDH) that was mainly hypodense compared to the neighboring brain tissue. There was evident compression of the right lateral ventricle, indicating mass effect. The cSDH was successfully evacuated via burr hole trephination.

Figure 2

The temporal course of thrombotic complications (TC) as a function of the use of antithrombotic drugs (AT).

eFigure 1

An 83-year-old woman was found lying on the floor with a right hemiparesis. There was no history of trauma in the weeks prior to the event. a) CT revealed a chronic subdural hematoma (cSDH), hypodense in relation to brain tissue, with some more acute components and septations. b–d): MRI on the same day revealed (b) marked hyperintensity of the hematoma compared to the cerebral cortex in the FLAIR sequence and (c) isointensity in the T1 sequence. After the administration of contrast medium (d), there was contrast enhancement of the inner and outer membranes of the SDH, and of the septations. The differential diagnosis of this finding includes empyema. Further MRI sequences can usually distinguish a subdural empyema from a chronic subdural hematoma. CT, computed tomography; MRI, magnetic resonance imaging.

eFigure 2

Flow chart of the literature review. 11 publications were included in the analysis. TC, thrombotic complications.