Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review

Middle meningeal artery embolization for chronic subdural hematoma in the nonagenarian population

BACKGROUND

The estimated incidence of chronic subdural hematomas (cSDH) in the general population is projected to nearly double over the next decade, likely making it the most commonly treated cranial neurosurgical condition in adults by 2030. We investigated the outcomes of middle meningeal artery embolization (MMAe) as either a primary or adjunctive treatment for cSDH in nonagenarian patients.

METHODS

We retrospectively reviewed all patients 90 years of age or older treated with middle meningeal artery embolization for cSDH from 2018 to 2024 at two academic institutions. Statistical analysis was performed on patient demographics, baseline functional status, intervention, cSDH size, recurrence rate, reintervention rate, and follow-up functional status.

RESULTS

Twenty-one patients aged 90 or older were identified who were treated with MMAe for cSDH. Hematoma thickness ranged from 10mm to 34mm with a mean midline shift of 4.6mm. Eighteen patients were treated with MMAe alone, while three patients underwent surgery followed by MMAe. A total of 20 patients had radiological follow up, with no evidence of growth or recurrence in 95 % of the patients. There was one recurrent cSDH in our cohort in the setting of new trauma after hospital discharge. There was one complication related to the MMAe procedure which was a femoral artery pseudoaneurysm that resolved without further treatment. Median baseline mRS was 3 prior to MMAe and median follow-up mRS after treatment was 2.

CONCLUSION

MMAe is a safe and efficacious treatment for nonagenarian patients with cSDH, and shows promise as a potential primary treatment modality.

Failure Rates of Conservative Management of Minimally Symptomatic Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

Conservative treatments for minimally symptomatic chronic subdural hematoma (cSDH) are debated, with surgery as the primary option.

OBJECTIVE

To assess failure rates of a conservative approach for management of cSDH.

METHODS

We searched PubMed, SCOPUS, Web of Science, and ClinicalTrials.gov for studies on conservative management of cSDH and analyzed the data using R (version 4.1.2).

RESULTS

A total of 35 studies including 2095 patients were analyzed: 950 (45%) of the patients were in the observation group, 671 (32%) in the corticosteroid group, 355 (17%) in the atorvastatin group, 43 (2%) in the mannitol group, 52 (2.5%) in the tranexamic acid group, and 24 (1.1%) in the etizolam group. Our pooled analysis showed that 19.82% of patients required rescue surgery (95% confidence interval [CI]: 12.98% to 26.66%, P < 0.0001). The overall pooled risk ratio (RR) for the effect of interventions on the need for rescue surgery was 0.2424 (95% CI: 0.1577 to 0.3725, Iˆ2 = 90.5%, P < 0.0001). Subgroup analysis showed varied effects: observation group (RR = 0.3482, 95% CI: 0.1045 to 1.1609, Iˆ2 = 94.0%), corticosteroids (RR = 0.2988, 95% CI: 0.1671 to 0.5344, Iˆ2 = 90.8%), atorvastatin (RR = 0.1609, 95% CI: 0.0985 to 0.2627, Iˆ2 = 53.2%), mannitol (RR = 0.0370, 95% CI: 0.0009 to 1.5244), and tranexamic acid (RR = 0.0585, 95% CI: 0.0026 to 1.2924).

CONCLUSIONS

The rate of rescue surgery in conservatively managed cSDH patients remains high. Corticosteroids or atorvastatin demonstrates some potential benefit in reducing the failure rate but collective effectiveness is unknown.

Updates on the diagnosis and management of subdural hematoma

ABSTRACT

Intracranial hemorrhage is a potentially life-threatening condition categorized into four main groups by the location of bleeding: epidural, subdural, subarachnoid, and intraparenchymal. Subdural hematoma (SDH) is increasingly common as the population of older adults increases. Clinicians must recognize the typical presentations and order diagnostic imaging studies to make a timely diagnosis and referral to neurosurgery for definitive treatment. Understanding the pathophysiology and risk factors for chronic or expanding SDH informs decision-making in managing anticoagulants. Emerging treatments offer potential alternatives to the traditional evacuation of SDH by craniotomy, which remains the standard of care for most symptomatic patients.

Additional treatment after primary conservative treatment in patients with chronic subdural hematoma-A retrospective study

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological condition and is typically treated with burr hole craniostomy. Nevertheless, conservative treatment may lead to spontaneous hematoma resolution in some patients. This study aims to describe the characteristics of patients who were treated conservatively without the eventual need for additional treatment.

METHODS

Data were retrospectively collected from patients who were primarily treated conservatively in three hospitals in the Netherlands from 2008 to 2018. The Primary outcome was the nonnecessity of additional treatment within 3 months after the initial CSDH diagnosis. We used univariable and multivariable logistic regression analyses to identify factors associated with not receiving additional treatment.

RESULTS

In this study, 83 patients were included and 61 patients (73%) did not receive additional treatment within 3 months. Upon first presentation, the patients had a Markwalder Grading Scale score (MGS) of 0 (n = 5, 6%), 1 (n = 43, 52%), and 2 (n = 35, 42%). Additional treatment was less often received by patients with smaller hematoma volumes (adjusted odds ratio [aOR] 0.78 per 10 mL; 95% confidence interval [CI] 0.64-0.92). Patients using antithrombotic medication also received less additional treatment, but this association was not significant (aOR 2.02; 95% CI 0.61-6.69).

CONCLUSIONS

Three quarters of the initially conservatively treated CSDH patients do not receive additional management. Typically, these patients have smaller hematoma volumes. Further, prospective research is needed to distinguish which patients require surgical intervention and in whom primary conservative treatment suffices.

Do we need a neurosurgical frailty index?

Background

An increasing number of elderly patients now require neurosurgical intervention, and it is sometimes unclear if the benefits of surgery outweigh the risks, especially considering the confounding factor of numerous comorbidities and often poor functional states. Historically, many patients were denied surgery on the basis of age alone. This paper examines the current selection criteria being used to determine which patients get offered neurosurgical management and attempts to show if these patients have a good outcome. Particular focus is given to the increasing insight into the need to develop a neurosurgical frailty index.

Methods

Using a prospective cohort study, this study observed 324 consecutive patients (n) over a 3-month period who were ≥65 years of age at the time of referral or admission to the neurosurgical department of the Royal Hallamshire Hospital. It highlights the selection model used to determine if surgical intervention was in the patient's best interest and explores the reasons why some patients did not need to have surgery or were considered unsuitable for surgery. Strengths and weaknesses of different frailty indices and indicators of functional status currently in use are discussed, and how they differ between the patients who had surgery and those who did not.

Results

Sixty-one (18.83%) of n were operated on in the timeframe studied. Compared to patients not operated, they were younger, less frail, and more functionally independent. The 30-day mortality of patients who had surgery was 3.28%, and despite the stringent definition of poor outcomes, 65.57% of patients had good postoperative results overall, suggesting that the present selection model for surgery produces good outcomes. The independent variables that showed the greatest correlation with outcome were emergency surgery, the American Society of Anesthesiology grade, the Glasgow Coma Scale, and modified frailty index-5.

Conclusion

It would be ideal to carry out future studies of similar designs with a much larger sample size with the goal of improving existing selection criteria and possibly developing a neurosurgical frailty index.

Patient perception and satisfaction in awake burr hole trepanation under local anesthesia for evacuation of chronic subdural hematoma

Evacuation of chronic subdural hematoma (CSDH) will be one of the most common neurosurgical procedures in the future in the increasingly aging societies. Performing cranial surgery on awake patients may place a psychological burden on them. Aim of this study was to evaluate the psychological distress of patients during awake CSDH relief. Patients with awake evacuation of CSDH via burr hole trepanation were included in our monocentric prospective study. Patient perception and satisfaction were measured using standardized surveys 3-5 days and 6 months after surgery. Among other questionnaires, the Hospital Anxiety and Depression and the Impact of Event Scale, were used to quantify patients' stress. A total of 50 patients (mean age 72.9 years (range 51 - 92)) were included. During surgery, 28 patients reported pain (mean 4.1 (SD 3.3)). Postoperatively, 26 patients experienced pain (mean 2.7 (SD 2.6)). Patients' satisfaction with intraoperative communication was reported with a mean of 8.3 (SD 2.1). There was a significant negative correlation between intraoperatively perceived pain and satisfaction with intraoperative communication (p = 0.023). Good intraoperative communication during evacuation of CSDH in awake patients is associated with positive patient perception and correlates with pain reduction.

Comparison of surgical strategies in patients with chronic subdural haematoma: a protocol for a network meta-analysis

INTRODUCTION

Chronic subdural haematoma (CSDH) is one of the most common neurosurgical emergencies, especially in the elderly population. Surgery is the mainstay of treatment for CSDH. Some studies have suggested that some specific surgical strategies can have potential benefits for patients with CSDH; however, the best surgical method is still controversial. For a better understanding of surgical treatment for these patients, it is necessary to conduct a network meta-analysis to comprehensively compare the effects of medical treatment and different surgical methods.

METHODS AND ANALYSIS

This protocol has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Related studies published up to April 2023 will be searched in the following databases: PubMed, Embase, Scopus, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, VIP and Wanfang. Randomised controlled trials and non-randomised prospective studies comparing at least two different interventions for patients with CSDH will be included. Quality assessment will be conducted using Cochrane Collaboration's tool or the Newcastle-Ottawa Scale based on study design. The primary outcome will be the recurrence rates, and the secondary outcome will be the functional outcome at the end of follow-up. Pairwise and network meta-analyses will be conducted using STATA V.14 (StataCorp, College Station, Texas, USA). Mean ranks and the surface under the cumulative ranking curve will be used to evaluate each intervention. Statistical inconsistency assessment, subgroup analysis, sensitivity analysis and publication bias assessment will be performed.

ETHICS AND DISSEMINATION

Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022376829.

A prospective randomized controlled trial of the effect of the number of burr hole on chronic subdural hematoma recurrence: An institutional experience

OBJECTIVE

The purpose of this study was to compare the effect of single burr hole (SBH) versus double burr hole (DBH) drainage on the recurrence rate of chronic subdural hematoma (CSDH).

METHOD

Forty-four patients undergoing burr hole craniostomy (BHC) between July 2022 and December 2022 were enrolled in a randomized clinical trial (RCT) comparing SBH to DBH surgeries. The primary endpoint of this study was the recurrence rate of CSDH. Radiological characteristics such as midline shift, thickness, volume, density, type of hematoma, brain atrophy and so on were secondary endpoints.

RESULTS

Forty-four patients participated in this study. Twenty-two hematomas underwent SBH craniostomy, and the other 22 had DBH craniostomy. The mean age in the SBH and DBH groups were 68.59 ± 7.94 and 69.54 ± 10.58, respectively. In each group, the proportion of males (SBH=16; DBH=15) was higher than that of females (SBH=6; DBH=7). The mean surgery time in the SBH group was significantly less than in the DBH group (p = 0.001). However, the two groups had no statistically significant difference in the CSDH recurrence rate (p = 0.312).

CONCLUSION

Our findings showed that SBH craniostomy is equally effective as DBH craniostomy at draining hematomas and does not increase the recurrence rate. Contrarily, the SBH craniostomy had a shorter surgical duration than the DBH craniostomy. As a result, we recommend SBH surgeries for all patients, with emphasis on the elderly and those with severe comorbidities, as well as in situations with few surgical facilities and a high patient admission rate.

Subdural Hematomas in Adults and Children

Subdural hematoma is a common entity encountered by the neurosurgeon. The disease has acute, subacute, and chronic forms. Management of the disease changes according to the etiology of the lesion, yet the main goals are, as with most neurosurgical interventions, decompression of neural tissue and restoration of perfusion. Due to various forms and causes of the disease such as trauma, anticoagulant/antiaggregant use, arterial rupture, oncologic hemorrhages, intracranial hypotension, and idiopathic hemorrhages, several approaches for management have been documented in the literature. Herewith, we present various up-to-date management options for the disease.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.

Chronic subdural hematoma that developed after a diagnostic lumbar puncture: headache worsens with bilateral compression of jugular veins (Queckenstedt’s maneuver)

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