Clinical features of chronic subdural hematoma: neuropsychiatric and neuropsychologic changes in patients with chronic subdural hematoma

This article provides a background review of the cognitive and behavioral symptoms associated with chronic subdural hematoma (CSH). The areas addressed include the initial cognitive and behavioral symptom presentation, lateralization and localizing signs, differences between older and younger patients, and differential diagnosis. Although it is clear that behavioral and cognitive abnormalities are seen in CSH, further work is needed to objectively clarify the range of symptoms and signs.     

The surgical management of chronic subdural hematoma

Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: “subdural hematoma”, “craniotomy”, “burr-hole”, “management”, “anticoagulation”, “seizure prophylaxis”, “antiplatelet”, “mobilization”, and “surgical evacuation”, alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.     

老年人慢性硬膜下血肿的治疗

老年人慢性硬膜下血肿(ChronicSubduralHemorrhage,CSDH)是指年龄在60岁以上,伤后或病程超过3周以上的硬膜下血肿,临床除有最常见的颅内高压表现如头痛等症状外,由于是老年患者,所以临床上具有其一定特点。特将2000年至2002年本院收治的CSDH46例,报告分析如下。1临床资料1.1一般情况:男38例,女8例;年龄60～82岁,平均67.8岁,其中65～75岁者占86%。有明确头部外伤史32例,其余病人不能记忆有脑外伤史。伤后有短暂意识不清10例,病史最长者3年,13例有高血压病史。1.2症状及体征:有头痛、头晕36例,有恶心呕吐10例,有进行性痴呆、淡漠、嗜睡等…     

Advances in surgical treatment of chronic subdural hematoma

Chronic subdural hematoma(CSDH) represents one of the most frequent types of intracranial hemorrhage.Management of the patients with CSDH has been evolved through a vast variety of methods and techniques.Although there is general agreement that surgical therapy is usually the preferred treatment, there are few other neurosurgical conditions that spark such strong discussions and differences of opinion concerning the optimal surgical technique.In this paper, we review advances in surgical treatment of CSDH.     

Clinical factors of recurrent chronic subdural hematoma

The clinical, radiological, and operative factors of recurrent chronic subdural hematoma (CSDH) were retrospectively analyzed in 116 patients with CSDH in 134 hemispheres, treated by one burr hole surgery. The correlation of recurrence was evaluated with personal and clinical factors such as age, sex, history of head injury, and interval from onset of initial symptoms to hospitalization; laboratory findings such as bleeding tendency and liver function; computed tomography (CT) findings such as hematoma density and brain atrophy; and operative findings such as additional procedures and postoperative residual air. The recurrence group (RG) included 10 hemispheres (7.5%) in 10 patients (8.6%). The interval from onset of symptoms to hospitalization was significantly shorter in the RG than in the nonrecurrence group (NRG). Headache was more frequently seen in the RG than in the NRG. Density of hematoma on CT was classified into five types: Low, iso, and high density, niveau, and mixed, and the incidence of recurrence was 0%, 2.3%, 17.2%, 12.5%, and 6.5%, respectively. Larger amounts of residual air in the postoperative hematoma cavity were associated with recurrence of CSDH. CSDH that progresses rapidly in the acute stage and appears as high density on preoperative CT is associated with a high incidence of recurrence. Intraoperative air invasion to the hematoma cavity should be avoided to prevent recurrence.     

Clinical correlates of erythropoiesis in chronic subdural hematoma

Histologic investigation was performed in 38 out of 224 chronic subdural hematomas treated at our institution from 1978 to 1988. Nucleated red blood cells were found in 33% of the chronic subdural membranes examined. Additional sections were examined in 14 of these 38 patients, revealing erythroblasts in 57%. The clinical course and radiographic findings in the patients whose membranes contained erythroblasts were compared with those whose specimens did not. Neither history, presentation, size of hematoma, nor postoperative recovery differed from one group to the other. By comparing histologic and clinical findings, we are able to conclude that the production of erythrocytes by chronic subdural membranes is of no surgical significance.     

外伤性硬膜下积液演变的慢性硬膜下血肿

目的 探讨外伤性硬膜下积液演变为慢性硬膜下血肿的几率、机理和临床特点。方法 回顾性分析32例外伤性硬膜下积液演变为慢性硬膜下血肿患者的临床资料及有关文献。结果 本组16.7%的外伤性硬膜下积液病例演变为慢性硬膜下血肿;积液演变为血肿的时间为伤后22－100d;经钻颅血肿引流均治愈。结论 外伤性硬膜下积液是慢性硬膜下血肿的来源之一。发病年龄两极化,常发生在积液量少、保守治疗的慢性型病例中,致病方式常为减速性损伤及合并的颅脑损伤很轻微是外伤性硬莫膜下积液演变为慢性硬膜下血肿患者的临床特点。     

外伤性硬膜下积液演变成慢性硬膜下血肿的临床分析

本院自1993年1月至2003年1月,共收治外伤性硬膜下积液(TSE)135例,其中17例转化为慢性硬膜下血肿(CSDH)。现结合患者的临床资料和有关文献报道如下。1临床资料1.1一般资料:17例中,男12例,女5例;年龄1～10岁6例,11～60岁2例,60岁以上9例。受伤原因:坠落伤6例,打击伤3例,车祸伤8例。其中减速性损伤12例。患者均否认在外伤性硬膜下积液演变为慢性硬膜下血肿期间有头部再次受伤史。1.2临床表现:17例患者均表现为在外伤性硬膜下积液症状的基础上,出现症状加重或新症状、体征,或原症状、体征减轻或消失后再次出现或加重。患者演变为慢性硬膜下血…     

Outcome following surgical treatment of chronic subdural hematoma in the oldest-old population

As a result of the demographic shift in western societies, the mean age at presentation of patients suffering from chronic subdural hematomas (cSDH) is increasing. Therapeutic strategies, surgical and non-surgical, need to be reevaluated and adapted accordingly. Age is considered to be a positive risk factor for a higher perioperative morbidity and mortality. The purpose of this study is to determine if old age (≥85 years) should be seen as a contraindication for surgical treatment. Two groups (56 patients each) with cSDH over and below 85 years of age from a single neurosurgical department with well-defined surgical treatment guidelines were retrospectively analyzed. Clinical characteristics of the patients, localization, treatment, prior medication, and complications were compared. Outcome was measured by clinical improvement postoperatively and by the Glasgow Outcome Scale (GOS) at 1 month after surgery. Age ≥85 years was associated with higher GOS 1 month after surgery (p = 0.038). 51.8% (58) of all patients had a complete neurological recovery postoperatively, and 74% (43) of these patients were ≥85 years. Elderly patients suffered from a significantly higher complication rate (p < 0.001) with odds of having a complication 18.3 times higher (p < 0.001) compared to patients <85 years. Both groups had a comparable mean hospitalization time (9.8 days for patients ≥85 years and 9.5 days for patients <85 years). Old age has no negative impact on overall outcome after surgical therapy of cSDH. Despite significantly higher complication rate in elderly patients, the outcome assessed by the GOS at 1 month after surgery was significantly better in comparison to patients younger than 85 years. Old age does therefore not seem to be a contraindication for surgical treatment of cSDH.     

Chronic subdural hematoma: surgical management in 133 patients

One hundred and thirty-three patients with chronic subdural hematoma were treated surgically between 1943 and 1980. The patients, aged 5 to 84 years, were graded retrospectively according to the Bender scale; 28% were in Grades 3 and 4. There were 107 unilateral and 26 bilateral hematomas. The clots were removed mostly via burr-holes without drainage. The treatment of 121 patients included an active policy of brain expansion at operation and the postoperative management of intracranial hypotension by lumbar injection. Two patients died, for a mortality rate of 1.5%. The patients who died were 54 and 59 years old, both from among the 26 cases with bilateral lesions; 107 unilateral lesions were treated, with no deaths. None of 51 patients who were aged 61 years and over died. The mean postoperative stay was 17.2 days, and at 3 weeks 77% had been discharged home. Fifteen percent of survivors had permanent disabilities. The common residual deficits were personality and memory disorders, and there was hemiparesis in Grade 4 cases. The high-risk groups of chronic subdural hematoma were those in Grades 3 and 4, bilateral hematomas, and the elderly. These seemed to be benefited by brain inflation and lumbar injections for intracranial hypotension.     

Clinical forms and prognostic factors of chronic subdural hematoma in the adult

The most common clinical signs for chronic subdural hematoma in adults are: motor weakness, increased intracranial pressure, confusion and loss of consciousness. This pathology is more frequent in the elderly over 65 years, the diagnosis also being more difficult in this case. Some misleading clinical presentations may delay the decision to perform a CT scan to assess the diagnosis. Preoperative headaches and isodensity in CT-scan are features of good prognosis. Chronic alcoholism and postoperative pneumocephalus are related with poor prognosis.     

Physiopathology of chronic subdural hematoma

Coagulation, fibrinolysis and kinin-kallicrein system disorders could explain chronic subdural hematoma pathophysiology. The marked decrease in antithrombin III in the hematoma suggest that the decreased levels of clotting factors were caused by excessive coagulation resulting in clotting factors consumption. The decrease in alpha 2-antiplasmin with the increase of fibrin degradation products suggest that hyperfibrinolytic activity of the subdural hematoma. Coagulation and fibrinolysis disorders could explain repetitive hemorrhages from the outer membrane, which cause progressive enlargement of the hematoma. Kinin-kallicrein system disorders raise the hemorrhage by its action on the outer membrane. Nowadays, the earliest osmotic theory should reasonably be abandoned.