Management of chronic subdural haematoma

Abstract

The main conclusion of Thomas Santarius and colleagues' well done study (Sept 26, p 1067)1Santarius T Kirkpatrick PJ Ganesan D et al.Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial.Lancet. 2009; 374: 1067-1073Summary Full Text Full Text PDF PubMed Scopus (391) Google Scholar—that morbidity from chronic subdural haematoma is lower if a drain is placed postoperatively—will probably change the management of this condition around the world. However, we want to highlight some concerns. Chronic subdural haematomas respond strikingly to surgical drainage. Since the difference in 30-day mortality between the drain and non-drain groups was non-significant, the cause of death at 6 months might be unrelated to the recurrence of chronic subdural haematoma. Moreover, after the evacuation of chronic subdural haematomas, death is a rare event, and those that do occur are often not directly related to the complications of chronic subdural haematoma.2Gazzeri R Galarza M Neroni M Canova A Refice GM Esposito S Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma.Acta Neurochir (Wien). 2007; 149: 487-493Crossref PubMed Scopus (5) Google Scholar The precise answer to this question might be discovered at autopsy. In older people with brain atrophy, chronic subdural haematomas take more time to produce neurological deficits, and positive findings on brain imaging can be more accurate diagnostically than symptoms.3Weigel R Schmiedek P Krauss JK Outcome of contemporary surgery for chronic subdural haematoma: evidence based review.J Neurol Neurosurg Psychiatry. 2003; 74: 937-943Crossref PubMed Scopus (362) Google Scholar Thus, routine brain imaging, as done by some researchers, can be fruitful.4Koivisto T Jääskeläinen JE Chronic subdural haematoma—to drain or not to drain?.Lancet. 2009; 374: 1040-1041Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Santarius and colleagues mention that they did not routinely do postoperative brain imaging. Thus, it is not clear whether they discharged any symptomatic patients without brain imaging, since there were few patients with neurological deficit at time of discharge. Finally, subjective assessment of patients by use of questionnaires may be inaccurate, especially in patients with mild neurological deficits, and could result in small haematomas being missed, although such small lesions may not have clinical importance. We declare that we have no conflicts of interest. Management of chronic subdural haematoma – Authors' replyVafa Rahimi-Movaghar and colleagues query the cause of death at 6 months. Mortality was a secondary endpoint in our study, but there were nine deaths at 6 months in the drain group and 19 in the non-drain group (p=0·042). Unfortunately, autopsies are not routinely done in the UK. However, a systematic review of causes of death in chronic subdural haematoma is underway. Full-Text PDF