Results of treatment for chronic subdural hematoma

INTRODUCTION. Chronic subdural hematoma (CSDH) is a common neurosurgical pathology, usually in elderly patients, and the main cause of which is traumatic brain injury. Analysis of epidemiological data shows that the incidence of CSDH is increasing due to the increased use of anticoagulants and the growing elderly population. Surgical treatment is the standard treatment for this category of patients, although the options for this treatment strategy are still controversial.
AIM. To analyze clinical outcomes in patients with CSDH in retrospective material depending on the strategy of surgical treatment.
MATERIALS AND METHODS. A total of 110 patients. There were 71 (64.5 %) men and 39 (35.5 %) women. The age ranged from 45 to 96 years, with a mean age of 73.8 years. CSDH was unilateral in 79 (71.8 %) patients and bilateral in 31 (28.2 %). The following surgeries were performed: craniostomy (twist drill) was performed in 7 (6.4 %) patients, burr-hole craniostomy in 83 (75.5 %) cases, craniotomy in 5 (4.5 %) patients, craniectomy in 2 (1.8 %) patients, middle meningeal artery embolization in 10 (9.1 %) cases, and combined treatment (craniostomy + embolization) in 3 (2.7 %) patients.
RESULTS. When studying the GCS data, statistically significant improvement of the indicator in the postoperative period was revealed in most patients compared with the preoperative data (p=0.001); When assessing the neurological status, complete regression of neurological symptoms was achieved in 73 (66.4 %) patients, partial regression of neurological symptoms was observed in 20 (18.2 %) cases, no dynamics in the neurological status was noted in 8 (7.3 %) patients, an increase in neurological deficit was noted in 4 (3.6 %) cases, and 5 (4.5 %) patients died. Relapse was recorded in 13 (11.8 %) cases, and complications were found in 8 (7.3 %) patients. Patients with periosteal drainage had fewer relapses and a better neurological outcome in the early postoperative period compared to patients with subdural drainage. Patients who underwent middle meningeal artery embolization had no recurrence and fewer days of hospitalization.
CONCLUSIONS. The choice of the optimal treatment method for CSDH is within the competence of the neurosurgeon and is determined for each patient individually; as a rule, such an individual approach will allow for the best result.

1. Iorio-Morin C., Touchette C., Lévesque M., Effendi K., Fortin D., Mathieu D. Chronic Subdural Hematoma: Toward a New Management Paradigm for an Increasingly Complex Population. Journal of Neurotrauma. 2018;35(16): 1882–1885. Doi: https://doi.org/10.1089/neu.2018.5872.

2. Yadav Y. R., Parihar V., Namdev H., Bajaj J. Chronic subdural hematoma. Asian Journal Neurosurgery. 2016;11(4):330–342. Doi: https://doi.org/10.4103/1793-5482.145102.

3. Yang W., Huang J. Chronic Subdural Hematoma: Epidemiology and Natural History. Neurosurg. Clin. N. Am. 2017;28(2):205–210. Doi: https://doi.org/10.1016/j.nec.2016.11.002.

4. Rauhal M., Luoto T. M., Huhtala H., Iverson G. L., Niskakangas T., Öhman J., Helén P. The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population. Journal of Neurosurgery. 2019;22(132(4)): 1147–1157. Doi: https://doi.org/10.3171/2018.12.JNS183035.

5. Rauhala M., Helén P., Huhtala H., Heikkilä P., Iverson G.L., Niskakangas T., Öhman J., Luoto T. M. Chronic subdural hematoma-incidence, complications, and financial impact. Acta Neurochirurgica (Wien). 2020;162(9):2033–2043. Doi: https://doi.org/10.1007/s00701-020-04398-3.

6. Uno M., Toi Hirai H. S. Chronic subdural hematoma in elderly patients: Is this disease benign?. Neurol Med Chir. 2017;(57):402–409. Doi: https://doi.org/10.2176/nmc.ra.2016-0337.

7. Likhterman L. B., Kravchuk A .D., Okhlopkov V. A. Chronic subdural hematomas: challenges and solutions. Part I: Clinical variants and diagnosis. Clinical review for general practice. 2021;(2):210–270. (In Russ.). Doi: https://doi.org/10.47407/kr2021.2.2.00038.

8. Miah I. P., Tank Y., Rosendaal F. R. et al. Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology. 2021;63(1):27–40. Doi: https://doi.org/10.1007/s00234-020-02558-x.

9. Holl D. C., Chari A., Iorio-Morin C. et al. Study protocol on defining core outcomes and data elements in chronic subdural haematoma. Neurosurgery. 2021;89(4):720–725. Doi: https://doi.org/10.1093/neuros/nyab268.

10. Holl D. C., Volovici V., Dirven C. M. et al. Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir. 2019;161(6):1231–1242. Doi: https://doi.org/10.1007/s00701-019-03881-w.

11. Kolias A. G., Chari A., Santarius T., Hutchinson P. J. Chronic subdural haematoma: modern management and emerging therapies. Nature Reviews Neurology. 2014;10(10):570–578. Doi: https://doi.org/10.1038/nrneurol.2014.163.

12. Lee K. S. How to Treat Chronic Subdural Hematoma? Past and Now. J Korean Neurosurg Soc. 2019;62(2):144–152. Doi: https://doi.org/10.3340/jkns.2018.0156.

13. Abecassis I. J., Kim L. J. Craniotomy for treatment of chronic subdural hematoma. Neurosurg. Clin. 2017;28(2):229–237. Doi: https://doi.org/10.1016/j.nec.2016.11.005.

14. Ban S. P., Hwang G., Byoun H. S. et al. Middle meningeal artery embolization for chronic subdural hematoma. Radiology. 2018;286(3):992–999. Doi: https://doi.org/10.1148/radiol.2017170053.

15. Choi J., Pyen J., Cho S., Kim J., Koo Y., Whang K. Influence of Antithrombotic Medication on the Risk of Chronic Subdural Hematoma Recurrence after Burr-Hole Surgery. Journal of Korean Neurosurgical Society 2020;63(4):513–518. Doi: https://doi.org/10.3340/jkns.2019.0194.

16. Greuter L., Hejrati N., Soleman J. Type of drain in chronic subdural hematoma-A systematic review and meta-analysis. Front. Neurol. 2020;(11):312. Doi: https://doi.org/10.3389/fneur.2020.00312.

17. Hutchinson P. J., Edlmann E., Bulters D., Zolnourian A., Holton P., Suttner N., Agyemang K., Thomson S., Anderson I. A., Thomson S., Anderson I. A., Al-Tamimi Y. Z., Henderson D. Trial of dexamethasone for chronic subdural hematoma. New England J. Med. 2020;383(27)2616–2627. Doi: https://doi.org/10.1056/NEJMoa2020473.

18. Nassiri F., Hachem L. D., Wang J. Z. et al. Reinitiation of anticoagulation after surgical evacuation of subdural hematomas. World Neurosurgery. 2020;(135):e616–e622. Doi: https://doi.org/10.1016/j.wneu.2019.12.080.

19. Petrov A., Ivanov A., Rozhchenko L., Petrova A., Bhogal P., Cimpoca A., Henkes H. Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid). Journal of Clinical Medicine. 2021;10(19):4436. Doi: https://doi.org/10.3390/jcm10194436.

20. Petrov A., Ivanov A., Dryagina N., Petrova A., Samochernykh K., Rozhchenko L. Angiogenetic Factors in Chronic Subdural Hematoma Development. Diagnostics (Basel). 2022;12(11):2787. Doi: https://doi.org/10.3390/diagnostics12112787.

21. Schucht P., Fischer U., Fung C. et al. Follow-up computed tomography after evacuation of chronic subdural hematoma. N. Engl. J. Med. 2019;(380):1186–1187. Doi: https://doi.org/10.1056/NEJMc1812507.

22. Soleman J., Lutz K., Schaedelin S. et al. Subperiosteal vs subdural drain after burr-hole drainage of chronic subdural hematoma: a randomized clinical trial (cSDH-Drain-Trial) Neurosurgery. 2019;85(5):E825–Е834. Doi: https://doi.org/10.1093/neuros/nyz095.

23. Solou M., Ydreos I., Gavra M., Papadopoulos E. K., Banos S., Boviatsis E. J., Savvanis G., Stavrinou L. C. Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics. 2022;12(9):2060. Doi: https://doi.org/10.3390/diagnostics12092060.

24. Tawab M., Reda M., El-Fiki A. Endoscopic Assisted Microscopic Fenestration of Inner Membrane in Cases of Chronic Subdural Hematoma. Open Journal of Modern Neurosurgery. 2019;(9):172–183. Doi: https://doi.org/10.4236/ojmn.2019.92017.

25. Waqas M., Vakhari K., Weimer P. V., Hashmi E., Davies J. M., Siddiqui A. H. Safety and effectiveness of embolization for chronic subdural hematoma: systematic review and case series. World Neurosurg. 2019;(126):228–236. Doi: https://doi.org/10.1016/j.wneu.2019.02.208.

26. Belkhair S., Pickett G. One versus double burr holes for treating chronic subdural hematoma meta-analysis. Can J Neurol Sci. 2013;40(1):56–60. Doi: https://doi.org/10.1017/s0317167100012956.

27. Han H. J., Park C. W., Kim E. Y., Yoo C. J., Kim Y. B., Kim W. K. One vs. two burr hole craniostomy in surgical treatment of chronicsubdural hematoma. J Korean Neurosurg Soc. 2009;46(2):87–92. Doi: https://doi.org/10.3340/jkns.2009.46.2.87.

28. Taussky P., Fandino J., Landolt H. Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma. Br J Neurosurg. 2008;22(2):279–282. Doi: https://doi.org/10.1080/02688690701818885.

29. Yamamoto H., Hirashima Y., Hamada H., Hayashi N., Origasa H., Endo S. Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model. J Neurosurg. 2003;98(6):1217–1221. Doi: https://doi.org/10.3171/jns.2003.98.6.1217.

30. Mersha A., Abat S., Temesgen T., Nebyou A. Outcome of chronic subdural hematoma treated with single burr hole under local anesthesia. Ethiop J Health Sci. 2020;30(1):101–106. Doi: https://doi.org/10.4314/ejhs.v30i1.13.

31. Petrov A. E., Rozhchenko L. V., Ivanov A. A., Bobinov V. V., Henkes H. The first experience of endovascular treatment of chronic subdural hematomas with non-adhesive embolization materials of various viscosities: Squid 12 and 18. Burdenko’s Journal of Neurosurgery. 2021;85(5):80–87. (In Russ.). Doi: https://doi.org/10.17116/neiro20218505180.

32. Stanishevsky A. V., Babichev K. N., Vinogradov E. V., Gizatullin Sh. Kh., Svistov D. V., Kandyba D. V., Savello A. V. Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review. Burdenko’s Journal of Neurosurgery. 2021;85(5):71–79. (In Russ.). Doi: https://doi.org/10.17116/neiro20218505171.

33. Guzel A., Kaya S., Ozkan U., Aluclu M. U., Ceviz A., Belen D. Surgical treatment of chronic subdural haematoma under monitored anaesthesia care. Swiss Med Wkly. 2008;138(27–28):398–403. Doi: https://doi.org/10.4414/smw.2008.12121.