Surgical Management of Chronic Subdural Hematomas: An Institutional Analysis of Time to Hematoma Resolution

Chronic subdural hematoma (CSDH) management is evolving with the increasing use of middle meningeal artery embolization (MMAE). Limited data exist on the time to resolution (TTR) across different interventions. The aim of this study was to establish a baseline TTR for surgically treated CSDHs before MMAE implementation and compare it with TTR of MMAE.

A retrospective analysis of 94 surgically treated CSDHs in 75 patients was performed. Kaplan-Meier survival analysis was used to model TTR for patients undergoing burr hole craniostomy (BHC), craniotomy, and twist drill craniostomy/subdural evacuating port system placement. Univariate and multivariate Cox regression analyses were performed to identify predictors of TTR. An unmatched cohort of 43 patients undergoing MMAE alone was underwent TTR analysis and compared with the surgical arm.

The median TTR for surgically treated CSDHs was 11 weeks, without significant difference between BHC and craniotomy groups. The median TTR for MMAE-treated patients was 14 weeks, significantly longer than craniotomy (P = .03) but not BHC (P = .12). Spontaneous resolution was observed in all conservatively managed hematomas in bilateral CSDH that received unilateral treatment, with a median TTR of 12 weeks. Preoperative warfarin use (hazard ratio = 2.19, 95% CI 1.20-3.85; P = .01) and liver disease (hazard ratio = 2.96, 95% CI 1.04-8.44; P = .04) were associated with shorter TTR on multivariate analysis. Total mortality of surgically managed patients was 9.3% and 20% at 1 and 3 years, respectively.

Resolution of CSDH commonly requires several months regardless of intervention type. Radiographic and clinical follow-up is widely variable. Although decompressive strategies achieve faster relief of mass effect and symptoms, interventions should consider the TTR and ability of patient to follow-up. Recognition of CSDH as a sentinel health event emphasizes the need for individualized treatment and long-term follow-up strategies.