Working Toward Rational and Evidence-Based Treatment of Chronic Subdural Hematoma
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outcomes were mortality at 30 days and 6 months and functional status (modified Rankin scale 99 ) at discharge and 6 months (Table 3). At 6 months, recurrence occurred in 10 of 108 patients (9.3%) treated with a drain and 26 of 107 (24%) without a drain (P = .003). There was lower mortality in the drain group at both 30 days and at 6 months, although only at 6 months was the difference statistically significant (Table 3). Patients left the hospital in better functional status if they were treated with a drain, and this advantage was maintained at 6 months (Table 3). Medical and surgical complications were much the same between the study groups. In accordance with the previously published studies, the results of this trial provide strong evidence for the use of drains with BHC. Several groups have demonstrated benefit from intra- operative irrigation. 100-103
Only Kuroki et al found . 6 times higher recurrence (P = .49) in cases with (5 of 45, 11.1%) than without (1 of 55, 1.8%) irrigation. Conversely, Aoki in a study of TDC (without the use of postoperative drains) found a lower recurrence rate in the cases when intraoperative irrigation was used (1 of 15 versus 7 of 24; P = .096). Collectively, these findings provide little support for the hypothesis that a reduction in the concentration of profibri- nolytic factors in the subdural fluid is the basis for the curative effect of the drainage procedure (see above). It has to be pointed out that none of the studies cited here were sufficiently powered to demonstrate such a difference. In contrast, 2 studies in which postoperative continuous irrigation was used showed that it is associated with a lower recurrence rate. 105,106 Most surgeons use 2 burr holes, mainly because doing so allows better washout of the subdural cavity. Taussky et al
107 have found higher recurrence rate if 1 rather than 2 burr holes was used. In contrast, in the series by Han et al, 108
the recurrence rate was 1 of 51 (2%) if 1 burr hole and 9 of 129 (7%) if 2 burr holes were used. This difference was not statistically significant (P = .19). Both studies were retro- spective series, and a number of factors, including the decision making as to when 1 or 2 burr holes should be drilled, may have been responsible for obtaining such disparate results. If drains are used, it seems to be more advantageous to insert them via frontal burr hole because this technique was found to be associated with lower recurrence. 109,110 Craniotomy Until the mid-1960s, craniotomy was the prevailing technique used to evacuate CSDH. 111,112 In 1964, Svien and Gelety 112
published a series of 69 patients with primary CSDH TABLE 1. Presentation of Patients With Chronic Subdural Hematoma Santarius et al 88 Mori and Maeda 86 Sambasivan 83 Krup and Jans 141 McKissock et al 142 Country
England Japan
India Germany
England Year
2009 2001
1997 1995
1960 Average age 77 69
a 65 49 a Series size 215 500
2300 212
216 Gait disturbance or falls 54 63
. . Mental deterioration 33 25 . . . Limb weakness 33 59 . 45 22 Acute confusion 31 . . 18 38 Headache 17 38 15 41 81 Drowsiness or coma 9 17 15 65 47 Speech impairment 6 2 . 18 6 Nonspecific deterioration 3 . . . . Collapse 1 . . . . Seizures 1 2 12 6 9 Incontinence 1 17 . . - Visual disturbance 1 . 12 . 13 Vomiting 1 3 . 11 30 Vertigo . . . 12 6 Strokelike symptoms b . . 29 . . Behavioral disturbance b . . 18 . . The series were selected arbitrarily to illustrate the presentation of patients with chronic subdural hematoma in different series. Only series with . 200 cases and those with clinical presentations specifically listed were considered. a These series included pediatric cases. b Naming and classification of symptoms and signs differed between series. They were made to fit categories used in our recent publication. 88 Only when this was not possible were the original categories retained. 116
q 2010 The Congress of Neurological Surgeons Santarius et al Clinical Neurosurgery
Volume 57, 2010 treated with either craniotomy or BHC. They found that the recurrence rate and functional outcome were better in patients treated with BHC than those who received craniotomy. Although the size of the series is rather small and the study falls short of today’s expected methodological rigor, numerous prospective and retrospective case series that followed and 2 meta-analyses have confirmed the findings of Svien and Gekety.
2,90 Nevertheless, many surgeons use minicraniotomies as the method of choice for evacuation of CSDH, and good results with the use of craniotomy, in terms of both recurrence and functional outcome, have been reported by a number of teams.
111,113-115 Craniotomy and BHC have not been compared in an appropriately powered clinical trial. The results of the study by Tanikawa et al 116 suggest that hematomas with multilayer structure of hematoma membranes demonstrated by T2*-weighted magnetic resonance imaging are more TABLE 2. Predisposing Factors for the Development and Recurrence of Chronic Subdural Hematoma a Factor Predisposing to Occurrence (Positive or Negative Association) Predisposing to Recurrence (Positive or Negative Association) Age All articles Positive 86,94
Male sex All articles Positive 94 History of head injury All articles History of falls Positive 133,143,144 Epilepsy Positive
133 Positive
145 Diabetes mellitus Negative 145
Alcoholism Positive
26,133,146 Positive
147,148 Anticoagulation/coagulopathies Positive 133,68,146,147,149,150–154 Positive 26,143
Neutral 155,156
Antiplatelet agents Positive
33,126,143,149,151,153,157 ACE inhibitors Negative 53 Negative 53 Low-ICP states Positive 33,158–162 High density on preoperative CT Positive
163 Width of hematoma on preoperative CT Positive 145
Midline shift . 5 mm on preoperative CT Positive
164 Multiplicity of hematoma cavities on preoperative CT Negative 145
Homogeneous type on preoperative CT Negative
164 Homogeneous type on preoperative CT Negative 165
Separated type on preoperative CT Positive
56,164,165 Evidence of cerebral infarction on preoperative CT Positive 86,166
Brain atrophy Positive
48,159,167 Positive
166,168 Subdural hygroma Positive 20,21,23,169 Poor brain expansion NA Positive 26,86,89,135,164 Thick subdural membrane Positive 89 Preoperative irrigation Positive 104,170
Postoperative irrigation Negative
105 Subtemporal marsupialization Negative 83 Placement of subdural drains Negative 84,88,89,94,96–98 Placement of subgaleal/subperiosteal drains Negative
87,95 Frontal position of drain Negative 109,171
Postoperative bed rest Negative1 40 Neutral1
39 Postoperative air on CT 110,86,94,148,163,164,168,170,172,173 High postoperative volume on CT Positive 171
Higher GOS at discharge Positive
163 High levels of b-trace protein in subdural fluid Positive 28 High concentration of tPA in subdural fluid Positive 42 a ACE, angiotensin-converting enzyme; CT, computed tomography; GOS, Glasgow Outcome score; ICP, intracranial pressure; tPA, tissue plasminogen activator. This table lists factors that have been reported in the literature as associated with or predictive of development or recurrence of CSDH. There was a great variation in the quality of evidence for the role of individual factors. Whenever possible, we tried to preserve the original description of each factor. This resulted in a degree of redundancy because some listed factors represent different aspects or merely different description of the same phenomenon (ie, brain atrophy, age, width of hematoma, evidence of infarct on the CT, lack of preoperative or postoperative brain expansion, high postoperative volume on CT). q 2010 The Congress of Neurological Surgeons 117 Clinical Neurosurgery
Volume 57, 2010 Chronic Subdural Haematoma-Review effectively treated with craniotomy than BHC. Future studies of imaging in the selection of the optimal surgical technique will likely define the role of craniotomy in the management of CSDH. In the meantime, most surgeons would agree with the statement from Markwalder 33 in a 1981 review that craniotomy should be considered in those instances in which the subdural collection reaccumulates, there is solid hematoma, or the brain fails to expand and obliterate the subdural space. TDC
In a recent paper, Rughani et al 117
reviewed the literature concerning TDC. The authors identified 16 articles published in English. 104,118-132 Weigel et al 2 have found that although the morbidity and mortality of TDC were similar to those of BHC, the recurrence rate was significantly greater than that of either BHC or craniotomy. The main advantage of TDC, however, is the possibility of performing it at bedside, which may be a con- sideration as the costs of operating theater time continue to rise. Conservative Management Our recent survey found that conservative management is rarely practiced in the United Kingdom and the Republic of Ireland. 93 Poorer outcome and prolonged hospital stay associated with conservative management are the main reasons for not pursuing this treatment option more often. 133-136 However, numerous cases of spontaneous resorption have been published, 137,138
and Delgado-Lo´pez et al 67 reported nonsurgical (dexamethasone-based) healing of up to two-thirds of 101 carefully selected CSDHs. Because surgical treatment brings about rapid improvement in patients’ clinical condition, overall, operative management is the treatment of choice, and conservative management tends to be reserved for patients who either are asymptomatic or have a high perceived operative risk. Adjuvant Treatment Approximately 55% of surgeons in Canada and the British Isles prescribe postoperative bed rest after the evacuation of CSDH.
91,93 This lack of consensus is consistent with the status of the available evidence. In a randomized trial, Nakajima et al
139 prospectively divided 46 patients into 2 groups of 23 patients. One group was kept flat for 3 days, and the other was allowed to sit up. The recurrence rates were 14.3% and 16%, respectively, and the difference was not significant. Abouzari et al
140 recently conducted a similar prospective randomized study with a 3-month follow-up and greater statistical power (84 patients). The recurrence rate was 2.3% in the supine group and 19% in the sitting group. There were significant differences in the incidence of atelectasis, pneumonia, bedsores, and deep venous thrombosis between the groups. These data suggest that there is a role for postoperative bed rest, but it is unclear whether the same reduction in risk of recurrence could be obtained with , 3 days of bed rest, as currently practiced by 93% of British and 99% of Canadian neurosurgeons. 91,93
The potential role of corticosteroids and ACE inhibitors in the management of CSDH is discussed in the Pathophys- iology section. SUMMARY
Surgical drainage is a relatively safe and effective treatment for CSDH. Class II evidence exists for BHC being the treatment of choice for an uncomplicated primary CSDH. Together with previously published literature, our recent randomized controlled trial provides Class I evidence for the use of a drain with BHC. Craniotomy and TDC also play a role in the management of CSDH, but more clinical research is needed to refine their specific indications. Many other technical variations have been described, but they have largely been driven by tradition, hypotheses, personal or departmental experience, or case series. A similar level of evidence exists for nonsurgical management that, most would agree, is best reserved for patients who either are asymptomatic or have a high perceived operative risk. In addition to steroids, ACE inhibitors may also play a role in the management of CSDH. A one-for-all management strategy is clearly not appropriate. Creating rational bases for the selection of an ideal treatment strategy for an individual patient should, in our opinion, be one of the targets in the process of improving the management of patients with CSDH. This can be achieved through better understanding of the nature of the condition through systematic basic science research, ascertaining the merits of different surgical techniques in well-designed and rigorously executed clinical trials, using advances in imaging techniques to classify CSDH (a subject not addressed here), and training and ongoing refinement of clinical acumen and surgical skills of individual surgeons. Disclosure Dr Hutchinson is supported by an Academy of Medical Sciences/Health Foundation Senior Surgical Scientist Fellow- ship. The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article. TABLE 3. Summary of Results of the Cambridge Chronic Subdural Haematoma Trial 88 Drain Group, n (%) Nondrain
Group, n (%) P Recurrence rate at 6 mo 10/108 (9.3) 26/107 (24) .003 Mortality at 30 d 4/106 (3.7) 8/105 (7.6) .191 Mortality at 6 mo 9/105 (8.6) 19/105 (18.1) .042 Favorable modified Rankin scale at discharge 81/97 (84) 64/95 (67) .009
Favorable modified Rankin scale at 6 mo 64/76 (84) 60/85 (71) .040 118
q 2010 The Congress of Neurological Surgeons Santarius et al Clinical Neurosurgery
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