Chronic subdural hematoma

Introduction
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By Ravindra Kumar Garg MD

Chronic subdural hematoma is one of the most frequent neurosurgical conditions. It is frequently encountered in elderly people, (usually, after minor head trauma) and in patients on long-term anticoagulation and long-term hemodialysis. Bilateral chronic subdural hematoma tended to occur more in patients with anticoagulant or antiplatelet therapy. The most frequent presenting symptoms are headache, cognitive decline, and focal neurologic deficit. Cognitive decline includes confusional state, psychomotor slowing, gait abnormalities, and subacute dementia. Chronic subdural hematomas often present with atypical and unusual manifestations and can be difficult to diagnose. A high index of suspicion is needed to make the early diagnosis. Patients require surgical hematoma evacuation. The common surgical procedures for chronic subdural hematoma include twist drill craniostomy, burr hole evacuation, or craniotomy. Eighty percent of patients recover completely. Infrequently, hematoma may recur. Instillation of tissue plasminogen activator increases the volume of hematoma drained and significantly reduces the incidence of recurrence. In one study, the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate. In this clinical summary, Dr. Ravindra Kumar Garg, Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh in Lucknow, India, discusses the pathophysiology, clinical presentation, impact on outcome, and available treatments for chronic subdural hematoma.

Key Points

  • Almost all chronic subdural hematomas result from modest cranial trauma.
  • The most frequent presenting symptoms are headache, cognitive decline, gait abnormalities, and hemiparesis.
  • A high index of suspicion is important for diagnosis.
  • The outcome is generally favorable with neurosurgical evacuation of hematoma.
  • However, the incidence of recurrent hematoma varies from 3.7% to 30% after surgery.