Abstract
Chronic subdural haematoma (CSDH) is a common neurological condition that usually affects the elderly. The optimal treatment strategy remains uncertain, principally because there is a lack of a good evidence base. In this paper, we review the literature concerning the peri-operative and operative care of patients. In particular, we highlight the non-surgical aspects of care that might impact on patient outcomes and CSDH recurrence. We propose that an integrated approach to care in patients with CSDH, similar to care of fragility fractures in the elderly, may be an important strategy to improve patient care and outcomes.
Highlights
The incidence of chronic subdural haematoma (CSDH) increases with age, and after 70 years of age is 8·2/100,000/year [1]
Ducruet et al concluded that twist-drill craniotomy (TDC) should be the first-line treatment for patients who are high-risk surgical candidates with nonseptated CSDH, whilst craniotomy is reserved for patients with membranous CSDH or symptomatic recurrence
It has been hypothesised that the concurrent treatment of hypertension with angiotensin converting enzyme (ACE) inhibitors in patients with CSDH might lower the risk of recurrence after surgery
Summary
The incidence of chronic subdural haematoma (CSDH) increases with age, and after 70 years of age is 8·2/100,000/year [1]. This is important, because improving outcomes in this elderly and often frail population requires us to make informed decisions at all stages of their management, not just in the operating theatre. Other uncertainties include the benefit of corticosteroids as either a primary treatment or an adjunct to surgery and the need to administer agents to mitigate the biological effects of antiplatelet medication pre-operatively (e.g., platelet transfusion) [8, 9] We will review these in more detail. CSDHs often present several weeks or months after the index bleed, because as the initial acute haematoma liquefies it enlarges This increasing volume causes mass effect that manifests clinically. High concentrations of vascular endothelial growth factor (VEGF) have been demonstrated within the subdural fluid supporting the theory that ongoing angiogenesis and hyper-permeability of capillaries contributes to haematoma expansion [13]
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