Table of Contents
Primary Category
Neurocritical Care
P-Category
Secondary Category
S-Category
Authors:
Introduction
- Slow extravasation of blood into the subdural space between the dura and arachnoid membranes
- Commonly seen neurosurgical condition associated with high morbidity and mortality
Epidemiology
- Worldwide Incidence
- 3-4/100,000/year in patients <65 years of age
- 8-58/100,000/year in patients >65 years of age
- 286/100,000/year in patients >80 years of age
- May occur after weeks of minor head injury (usually >3 weeks)
- Usually affects elderly and those on anticoagulant therapy
- Estimated to affect 60,000 US population >65 years of age annually by 2030
- Male to female ratio: 3:1
- Bilateral in 20%
Etiology
- Rupture of bridging veins
- Risk factors
- Old age
- Anticoagulant/antiplatelet therapy
- Male gender
- History of falls
- Minor head trauma
- Bleeding disorders
- Seizure history
- Alcohol use
Figure 1: Chronic Subdural Hematoma on CT
Case courtesy of UoE Radiology, Radiopaedia.org, rID: 34063
Pathophysiology
- Initial trauma to the subarachnoid space leading to acute SDH→ fibrin accumulates→ organization, dissolution of fibrin and subdural hematoma→ activate inflammatory changes lead to collagen and fibroblast formation→ subdural neomembrane formation in more than 2 weeks→ formation of weak vascular capillaries that promote subsequent chronic subdural hematoma
- Subdural hygroma: accumulation of CSF in the subdural space→ new blood vessel formation takes place→ bleeding from these newly formed vessels lead to the development of chronic subdural hematoma
Clinical Features
- Headache
- Nausea/vomiting
- Mental status changes
- Disorientation.
- Lethargy
- Cognitive dysfunction (a cause of reversible dementia-like symptoms)
- Delirium
- Coma
- Seizures
- Focal neurological deficits
- Motor weakness
- Hemiparesis
- Hemisensory loss
- Speech problems
- Difficulty walking
- Stroke
Clinical progression
- The early period of injury
- Traumatic brain injury causes hematoma development, also known as “seed” for chronic SDH
- The latent period of hematoma growth
- Hematoma grows slowly
- Volume expansion
- Significant neovascularization
- Lasts weeks to years
- Usually asymptomatic
- The Period of clinical appearance
- Clinical manifestations from raised intracranial pressure by enlarging hematoma.
- Seizures
- Coma
- Brain herniation
Differential Diagnosis
- Lymphoma
- Metastasis
- Sarcoma
- Infectious
- Neurocysticercosis
- Bacterial empyema
- Autoimmune disorders:
- Wegener granulomatosis
- Rosai-Dorfmann disease
- Polyarteritis nodosa
Diagnosis
- CT Scan of Head: hypodense crescent-shaped mass but can be isodense or hyperdense
- Additional CT findings
- Grey-white junction shifts medially
- Convexity sulci do not extend to the inner part of the skull
- MRI of Brain
- May be used when alternative diagnoses are suspected
Treatment
- Focused physical examination
- Pupillary examination and GCS assessment
- Emergent resuscitation with assessment of airway, breathing, and circulation., followed by emergent neuroimaging (CT head without contrast)
- Neurosurgical consultation
- Adequate intravenous access
- Coagulopathy correction/reversal
- Steroids medications
- Antiepileptic medications: Phenytoin/fosphenytoin or Levetiracetam
- Non-operative treatment: indicated in
- Asymptomatic patients with small hematoma
- Moribund patients with poor baseline function
- Indication for Surgical intervention
- Any size that is symptomatic
- Radiological signs of significant brain compression
- Radiological signs of impending midline shift
- Radiologically more than 2mm
- Surgical Technique
- Burr hole craniotomy
- Most commonly used.
- Drilling burr hole over cerebral convexity.
- 2 burr holes 5-8cm apart are drilled.
- Dura is entered and irrigated with normal saline.
- Silicone drainage is placed into the subdural space and drainage is done by connecting to a drainage system.
- Drain removed after 48 hours.
- Done under general anesthesia.
- Twist drill craniotomy.
- Relatively safe and less invasive method.
- A small craniotomy is made using a hand drill.
- Done under local anesthesia.
- Higher recurrence rate.
- Craniotomy.
- Most invasive method used in the past.
- Used for old, organized, multiseptated SDH.
- Large bone flap is separated followed by irrigation and evacuation of the hematoma.
- Higher morbidity than other surgical procedures.
Complications
- Recurrence
- Seizures
- Subdural empyema
- Intracerebral hemorrhage
- Epidural hematoma
- Pneumocephalus
- Intracerebral abscess
- Meningitis
Prognosis
- Good clinical outcome after surgery in 80-90% of patients
- Death rate: 0.5-4.3%
- Recurrence rate nearly 70%
- 10-20% of recurring cases require repeated surgical management
Bibliography
- Asghar M, Adhiyaman V, Greenway MW, Bhowmick BK, Bates A. Chronic subdural haematoma in the elderly: a North Wales experience. J R Soc Med 2002;95:290–292.
- Bourgeois P, Sleiman M, Louis E, et al. Chronic subdural hematoma in patients over 80 years of age [in French]. Neurochirurgie 1999;45:124–128.
- Cousseau DH, Echevarria Martin G, Gaspari M, Gonorazky SE. Chronic and subacute subdural haematoma: an epidemiological study in a captive population [in Spanish]. Rev Neurol 2001;32:821–824.
- Adhiyaman V, Asghar M, Ganeshram KN, Bhowmick BK. Chronic subdural haematoma in the elderly. Postgrad Med J 2002;78:71–5.
- Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet (London, England) 2009;374:1067–73.
- Asghar M, Adhiyaman V, Greenway M, Bhowmick BK, Bates A. Chronic subdural haematoma in the elderly—a North Wales experience. Journal of the royal society of medicine. 2002;95(6):290-2.
- Miranda LB, Braxton E, Hobbs J, Quigley MR. Chronic subdural hematoma in the elderly: not a benign disease: clinical article. Journal of neurosurgery. 2011;114(1):72-6.
- Kolias AG, Chari A, Santarius T, et al. Chronic subdural haematoma: modern management and emerging therapies. Nat Rev Neurol 2014;10(10):570–8.
- Adhiyaman V, Asghar M, Ganeshram KN, et al. Chronic subdural haematoma in the elderly. Postgrad Med J 2002;78(916):71–5.
- Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001;41(8):371–81.
- Gelabert-Gonza´lez M, Iglesias-Pais M, Garcı´a-Allut A, et al. Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 2005;107(3):223–9.
- Ivamoto HS, Lemos HP, Atallah AN. Surgical treatments for chronic subdural hematomas: a comprehensive systematic review. World Neurosurg 2016; 86:399–418.
- Iliescu IA, Constantinescu AI. Clinical evolutional aspects of chronic subdural haematomas - literature review. J Med Life 2015;8(Spec Issue):26–33.
- Sambasivan M. An overview of chronic subdural hematoma: experience with 2300 cases. Surg Neurol 1997;47(5):418–22.
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