Chronic subdural hematoma

management: medical
treatment
CLAUDIO ALEXANDER RIVAS PALACIOS
Postgraduate Student Third Year
Specialization in Neurosurgery
Faculty of Medicine
University of Cartagena
2021

1
 Introduction
• It is one of the most common
neurosurgical pathologies
• Incidence ↑ with age ¹.
• In 50% of cases a history of TBI is
established ².
• The main therapeutic measure is
surgery.
• Alternative management therapies:
risk of recurrence.
• It is important to understand the
pathophysiological mechanisms.
1. Ducruet AF, et al. The surgical management of chronic subdural hematoma. Neurosurg Rev. 2012; 35:155-169.
2. He W.S, Velkoff V.A, De Barros K.A. 65þ in the U.S. In: U.S. Census Bureau, ed. Current Populations Reports. Special Studies. Washington, DC: United States
Government Printing Office; 2005. 2
3. Edlmann E, et al. Acta Neurochirurgica (2020) 162:763–776
Definition

It is a collection located in the

subdural space, whose blood
content has a low density of red
blood cells, and its evolution time
is between 3 weeks to 3 months.

3
 Etiopathogenesis and pathophysiology:
theories

1. Virchow R. Das hämatoma der dura mater. Vorgetragen in den Sitzungen. April 1856; Vom 26:134–142
2. Trotter W. Chronic subdural hemorrhage of traumatic origin and its relation to pachymeningitis haemorhhagica interna. Br J Surg. 1914;2: 271-291
3. Edlmann E. et al. Pathophysiology of chronic subdural haematoma. Journal of Neuroinflammation (2017) 14:108 4
4. Holl D.C. et al. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma. World Neurosurgery (2018) 116:402-411
 Etiopathogenesis and pathophysiology:
theories

1. Edlmann E. et al. Pathophysiology of chronic subdural haematoma. Journal of Neuroinflammation (2017) 14:108
2. Holl D.C. et al. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma. World Neurosurgery (2018) 116:402-411 5
 Etiopathogenesis and pathophysiology:
theories

Vasculogenesis, Coagulopathy,
Inflammatory angiogenesis, hyperfibrinolysi
pathway and growth s, and
factors exudation

1. Edlmann E. et al. Pathophysiology of chronic subdural haematoma. Journal of Neuroinflammation (2017) 14:108
2. Holl D.C. et al. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma. World Neurosurgery (2018) 116:402-411 6
 Tomographic patterns (classification): natural history

Nakaguchi Nomura
Laminar Hypodense
Homogeneous Isodense
Separated Hyperdense
Trabecular Mixed
Layering hematoma

1. Nakaguchi H, et al. Factors in the natural history of chronic subdural hematomas that influence their postoperative recurrence. J Neurosurg 2001; 95: 256–62.
2. Katano H, et al. Tissue plasminogen activator in chronic subdural hematomas as a predictor of recurrence. J Neurosurg 2006; 104: 79-84 7
3. You W, Zhu Y, et al. Acta Neurochirurgica (2018) 160:893–899
Management
• Surgical
• Endovascular: meningeal artery embolization
• Medical:
• Tranexamic Acid
• Steroids
• Statins

8
 Therapeutic approach
There are no standardized surgical
criteria.
Indication for surgery:
• Imaging: thickness > 10 mm,
deviation from the midline > 5 mm
• Clinical : GCS < 9, or a decrease in
this ≥ 2 points in relation to
admission, anisocoria and / or
focal motor deficit
• Tomographic patterns
1. Youmans & Winn, Neurological Surgery. 7th edition (2016). Medical and Surgical Management of Chronic Subdural Hematomas, Chap 34, pag 310-337
2. Greenberg, Handbook of Neurosurgery. 8th Edition (2016). Traumatic Hemorrhagic Conditions (Chap 58), pag 891-905
3. Amit Kumar Thotakura and Nageswara Rao Marabathina. World Neurosurg. (2015) 84, 6:1968-1972. 9
4. Markwalder TM. Chronic subdural hematomas: a review. J Neurosurg. 1981 May;54(5):637-45
World Neurosurg. (2018) 119:e374-e382. 10
Risk of recurrence

11
 • cSDH with a greater inflammatory process have a greater tendency to
bleed. ¹
• The laminar and mixed type  Both present recurrence after treatment.

1. Frati A, Salvati M, Mainniero F, Ippoliti F. Rocchi G, Raco A et al. J Neurosurg 2004, 100: 24-32
2. Jung-Kil Lee, et al. J Korean Neurosurg Soc 42 : 11-15, 2008 12
Injury 50 (2019) 1634–1640 13
Acta Neurochirurgica (2018) 160:893–899 14
Medical treatment

15
 Tranexamic acid
1. Post-surgical residual cSDH:
-Prevention of recurrence¹
2. Alternative treatment to surgical drainage:
-Prevention of recurrence by simultaneous
inhibition of inflammation and fibrinolysis²
3. Post-surgical assistant treatment (“new”
cSDH)
-Reduction of hematoma volume, does not
prevent recurrence ³
-Pending clinical outcome: double-blind
randomized clinical trial (TRACS)⁴
Safety: decreases mortality, and does not
increase risk of DVT and / or PTE⁵

1. Tanweer O. et al. World Neurosurg. (2016) 91:29-33 4. Iorio-Morin C. et al. TRACS. 2016. NCT ID: NCT02568124
2. Kageyama H. et al. J Neurosurg 119:332–337, 2013. 5. Jackson Chornenki N.L. et al Thromb Res.2019; 179: 81-86.
16
3. Yamada T. and Natori Y. World Neurosurg. (2020) 134:e549-e553.
Journal of Clinical Neuroscience 82 (2020) 147–154 17
 Steroids: dexamethasone
1. Recurrent cSDH:
-Avoid surgical reintervention ¹
2. Combined treatment with surgical
drainage (best indication) ²˒ ⁶
3. Alternative treatment to surgery:
-Midline displacement <10 mm³
-Markwalder 1 and 2 ⁴
-Randomized trial, blind to the evaluator
(ATO vs ATO + DXM) ⁵; phase III report
missing
Does not increase mortality ¹⁻⁴
1. Tang W. et al World Neurosurg. (2017) 105:115-121. 4. Delgado-López et al. Neurocirugía. 2009; 20: 346-359
2. Fotakopoulos G. et al. Interdisciplinary Neurosurgery 16 (2019) 70–74. 5. Jiang R. et al. J Neurosurg January 31, 2020
3. Thotakura A. K. et al. World Neurosurg. (2015) 84, 6:1968-1972. 6. Chao You et al. Acta Neurochir (2017) 159:2037–2044 18
 19
Holl D.C, Volovici V, et al. Acta Neurochirurgica (2019) 161:1231–1242
Journal of Clinical Neuroscience 71 (2020) 153–157 20
N Engl J Med 2020;383:2616-27 21
 Statins: atorvastatin
1. Andrade, S.P. et al. Biomedicine & Pharmacotherapy 64 (2010) 29–34
2. Galve, E. et al. Rev Esp Cardiol Supl. 2015;15(A):28-33
3. Liao, J.K. et al. Circulation. 1998;97:1129-1135
1. HMG CoA modulation:
-Inhibits angiogenesis by ↓ VEFG, TNFa and
TGF-ẞ1¹
-Improved endothelial function and decrease in
vascular inflammation: ↑ eNOS ↓ GTPase²˒ ³
2. Combined treatment with surgical drainage:
-Decreases risk of recurrence ⁴
3. Alternative treatment to surgical drainage:
-Markwalder 0-3 ⁵
-Randomized double-blind clinical trial (ATOCH):
> 65 years, > 30 mL ⁶
No increased mortality⁴˒ ⁵
4. Feng, H. et al. World Neurosurg. (2018) 117:e425-e429
5. Zhang J. et al. Journal of the Neurological Sciences 336 (2014) 237–242
6. Zhang, J. et al. JAMA Neurology.(2018)75: 1338-1346 22
Zhang, J. et al. JAMA Neurology.(2018)75: 1338-1346 23
Neurosurgical Review (2021) 44:479–484 24
Conclusions
• We must establish if the patient requires surgical management.
• We must establish the risk of recurrence.
• Atorvastatin is the drug with best level of evidence in reducing the
risk of recurrence of cSDH, and in the safety of its administration. The
dose considered is 20 mg every night for 6-8 weeks.
• There is no strong evidence in favor of the use of tranexamic acid as a
medical treatment for cSDH.
• Steroids increase the risk of major complications and long-term
disability, which can condition their use.

25