Chronic Subdural Hematoma (cSDH): A review of the current state of the art

Abstract

Introduction: Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies.

Research question: What is the state of the art of cSDH management.

Material and methods: Review.

Results: Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13-15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9-22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9-33%), occurring more commonly with older age and bilateral cSDHs.

Discussion and conclusion: While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment.

Keywords: Burr hole; Elderly; Head trauma; Injury; Surgery; Trepanation.

Fig. 1

Illustrations of a superior and lateral view of important anatomical landmarks to consider during surgical treatment of cSDH. A) The superior view highlights the placements of the burr-holes, with consideration of the motor cortex. Shown here is the subcutaneous/subgaleal drain placement which is preferred by the authors. B) The lateral view demonstrated the same Burr-hole placements but also demonstrated the skin incision for a conversion to a craniotomy. Anatomical landmarks are highlighted to demonstrated why this skin incision is preferred.