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Chronic Subdural Hematoma (cSDH): A review of the current state of the art
Aria Nouri1, Renato Gondar1, Karl Schaller1,2
1Department of Neurosurgery, Geneva University Hospitals, Switzerland.
Insights
Chronic subdural hematoma (cSDH) management is evolving, with burr-hole surgery as the gold standard. Emerging treatments like MMA embolization show promise for reducing cSDH recurrence.
Area of Science:
- Neurosurgery
- Neurology
- Radiology
Background:
- Chronic subdural hematoma (cSDH) incidence is increasing globally, driven by an aging population and wider antithrombotic medication use.
- Risk factors for cSDH include head trauma, antithrombotic use, and craniocerebral disproportion.
- cSDH commonly presents with disorientation and symptoms of increased intracranial pressure, with bilateral occurrence in 9-22% of cases.
Purpose of the Study:
- To review the current state-of-the-art in chronic subdural hematoma (cSDH) management.
- To explore the pathophysiology and risk factors associated with cSDH.
- To evaluate current and emerging treatment strategies for cSDH.
Main Methods:
- Systematic review of recent literature on cSDH management.
- Analysis of diagnostic imaging (CT) for assessing cSDH severity and guiding treatment.
- Evaluation of surgical and non-surgical treatment outcomes and complications.
Main Results:
- CT imaging is crucial for assessing cerebral compression, hematoma age, and membrane presence, guiding treatment urgency.
- Recurrence is a primary complication (9-33%), more frequent in older patients and bilateral cSDHs.
- Burr-hole surgery with subgaleal drains is the current gold standard for cSDH treatment.
Conclusions:
- Understanding cSDH pathophysiology, including the role of the middle meningeal artery (MMA), is advancing.
- MMA embolization is a promising new option to reduce cSDH recurrence.
- Steroid use in cSDH management remains controversial, lacking clear treatment guidelines.
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.
