Chronic Subdural Hematoma: Toward a New Management Paradigm for an Increasingly Complex Population

Area of Science:

• Neurosurgery
• Neurology
• Clinical Research

Background:

• Chronic subdural hematoma (cSDH) is a common neurological condition with increasing complexity due to aging populations and antithrombotic use.
• Current management strategies for cSDH have not significantly evolved since the late 1990s, despite changes in patient demographics and clinical presentations.
• There is a lack of universally accepted definitions and standardized data collection for cSDH, hindering research and clinical trial comparability.

Purpose of the Study:

• To review the current state of cSDH research globally, focusing on addressing critical evidence gaps in its diagnosis and management.
• To highlight ongoing research initiatives aimed at improving the classification, understanding, and treatment of cSDH.
• To propose a future vision for personalized cSDH management based on stratification for treatment and adjuvant therapies.

Main Methods:

• Review of ongoing cSDH research at Université de Sherbrooke and internationally.
• Discussion of projects addressing definition (CODE-CSDH), classification (ICD-11 amendment), and symptom research (GENESIS study).
• Overview of clinical trials investigating adjuvant therapies for high-risk patients: tranexamic acid (TRACS study) and embolization of the middle meningeal artery (EMMACS study).

Main Results:

• Evidence is lacking at multiple decision points within the standard cSDH treatment algorithm.
• Emerging evidence supports the recognition and investigation of nonepileptic, stereotypical, and intermittent symptoms (NESIS) in cSDH patients.
• Ongoing studies are evaluating the efficacy of tranexamic acid and embolization for reducing cSDH recurrence.

Conclusions:

• Standardizing cSDH definition and data collection is crucial for advancing research and improving classification.
• Further research is needed to understand and manage specific patient subpopulations, such as those with NESIS.
• Personalized treatment strategies, stratifying patients for operative versus conservative management and offering adjuvant therapies based on recurrence risk, hold promise for improving cSDH outcomes.