Chronic Subdural Hematoma
Manish KC, MBBS1, Junaid Siddiqui, MD, MRCP2
1KIST Medical College & Teaching Hospital, Nepal.
2Department of Neurology, University of Missouri, Columbia, USA
- Slow extravasation of blood into the subdural space between the dura and arachnoid membranes
- Commonly seen neurosurgical condition associated with high morbidity and mortality
- 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%
- 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
- 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
- Mental status changes
- Cognitive dysfunction (a cause of reversible dementia-like symptoms)
- Focal neurological deficits
- Motor weakness
- Hemisensoy loss
- Speech problems
- Difficulty walking
- 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.
- Brain herniation
Figure 1: Chronic Subdural Hematoma
Figure 1: Chronic Subdural Hematoma
- Bacterial empyema
- Autoimmune disorders:
- Wegener granulomatosis
- Rosai-Dorfmann disease
- Polyarteritis nodosa
- 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
- 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.
- 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.
- Burr hole craniotomy
- Subdural empyema
- Intracerebral hemorrhage
- Epidural hematoma
- Intracerebral abscess
- 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
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