Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature

Mehta, Vikram A.; Harward, Stephen C.; Sankey, Eric W.; Nayar, Gautam; Codd, Patrick J.

doi:10.1016/j.jocn.2018.01.050

Cited by 169 publications

(152 citation statements)

References 84 publications

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“…Conversely, CSDH itself has been associated with a significant increase in the degree of brain atrophy post-CSDH [4]. Other well-known risk factors for CSDH are trauma [26], alcohol overuse [28], and antithrombotic therapy [6,15,23,30].…”

Section: Introductionmentioning

confidence: 99%

Long-term excess mortality after chronic subdural hematoma

et al. 2020

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Objective To assess possible long-term excess mortality and causes of death of patients with chronic subdural hematoma (CSDH). Methods A retrospective study (1990-2015) of adult patients (n = 1133, median age = 76 years old, men = 65%) with CSDH identified by ICD-codes and verified by medical records. All patients were followed until death or the end of 2017. Cumulative relative survival ratios and relative excess risks of death (RER) were estimated by comparing patients' mortality with that in the entire regional matched population. The causes of death were compared with a separate reference group formed by randomly choosing sex, age, and calendar time matched controls (4 controls per each CSDH patient). Results The median follow-up time was 4.8 years (range = 0-27 years), and 710 (63%) of the patients died (median age at death = 84 years old). The cumulative excess mortality was 1 year = 9%, 5 years = 18%, 10 years = 27%, 15 years = 37%, and 20 years = 48%. A subgroup of CSDH patients (n = 206) with no comorbidity had no excess mortality. Excess mortality was related to poor modified Rankin score at admission (RER = 4.93) and at discharge (RER = 8.31), alcohol abuse (RER = 4.47), warfarin (RER = 2.94), age ≥ 80 years old (RER = 1.83), non-operative treatment (RER = 1.56), and non-traumatic etiology (RER = 1.69). Hematoma characteristics or recurrence were unrelated to excess mortality. Dementia was the most common cause of death among the CSDH patients (21%) and the third most common cause in the reference group (15%, p < 0.001). Conclusions Patients with CSDH have continuous excess mortality up to 20 years after diagnosis. Patient-related characteristics have a strong association with excess mortality, whereas specific CSDH-related findings do not. CSDH patients have an increased risk for dementia-related mortality.

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Section: Introductionmentioning

confidence: 99%

Long-term excess mortality after chronic subdural hematoma

et al. 2020

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“…The aging of the western population and the increasing use of oral anticoagulation (OAC) and antiplatelet drugs (APD) will likely result in an increased incidence of chronic subdural hematoma (cSDH) (1). Elderly patients have a 10-fold increase in the risk of developing cSDH, estimated around 58-200 per 100,000 per year, depending on their anticoagulation status (2).…”

Section: Introductionmentioning

confidence: 99%

“…Although the commonly used techniques are relatively safe and simple (1), cSDH have a mortality rate as high as 42% (5,6) and a recurrence rate up to 76% (1,7,8). Prediction models so far have been inconsistent (9)(10)(11)(12) and are not routinely implemented in clinical practice.…”

Section: Introductionmentioning

confidence: 99%

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Predicting Chronic Subdural Hematoma Recurrence and Stroke Outcomes While Withholding Antiplatelet and Anticoagulant Agents

et al. 2020

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The aging of the western population and the increased use of oral anticoagulation (OAC) and antiplatelet drugs (APD) will result in a clinical dilemma on how to balance the recurrence risk of chronic subdural hematoma (cSDH) with the risk of withholding blood thinners. Objective: To identify features that predicts recurrence, thromboembolism (TEE), hospital stay and mortality. To identify the optimal window for resuming APD or OAC. Methods: We performed a retrospective multivariate analysis of a prospectively collected database. We then build machine learning models for outcomes prediction. Results: We identified 596 patients. The rate of recurrence was 22.17%, that of thromboembolism was 0.9% and that of mortality was 14.78%. Smoking, platelet dysfunction, CKD, and alcohol use were independent predictors of higher recurrence, while resolution of the SDH was protective. OAC use had higher odds of developing TEEs. CKD, developing a new neurological deficit or a TEEs were independent predictors of higher mortality. We find the optimal time of resuming OAC to be after 2 days but before 21 days as these patients had the lowest recurrence of bleeding associated with a low risk of stroke. The ML model achieved an accuracy of 93, precision of 0.84 and recall of 0.80 for recurrence prediction. ML models for hospital stay performed poorly (R 2 = 0.33). ML model for stroke was overfitted given the low number of events. Conclusion: ML modeling is feasible. However, large well-designed prospective multicenter studies are needed for accurate ML so that clinicians can balance the risks of recurrence with the risk of TEEs, especially for high-risk anticoagulated patients.

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“…Furthermore, the elderly are known to be prone to the primary development of chronic haematona. [22][23][24] This is because elderly patients often have some brain atrophy that may accompany the development of cSDH.…”

Section: Discussionmentioning

confidence: 99%

Frequency of and Risk Factors for Chronification in Traumatic Acute Subdural Hematoma following Conservative Therapy

Kaestner

Boom

Deinsberger

2019

J Neurol Surg A Cent Eur Neurosurg

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Background In an aging society, traumatic head injuries, such as acute subdural hematomas (aSDHs), are increasingly common because the elderly are prone to falls and are often undergoing anticoagulation treatment. Especially in advanced age, cranial surgery such as craniotomies may put patients in further jeopardy. But if treatment is conservative, a chronic subdural hematoma (cSDH) may develop, requiring surgical evacuation. Existing studies have reported a correlation between several risk factors contributing to the frequency of chronification. To improve the prediction of the course of disease and to aid counseling patients and relatives, this study aimed to determine the frequency and the main risk factors influencing the process of chronification of an aSDH following conservative treatment. Methods We identified patients presenting between January 2012 and September 2017 at our neurosurgical department with an aSDH. All patients treated conservatively were selected retrospectively, and the following parameters were documented: age, sex, chronification status, Glasgow Coma Scale score on admission and discharge, hematoma thickness and density, the degree of midline shift (MLS), prior anticoagulants and administration of procoagulants, thrombosis management, other coagulopathies, initial length of hospital stay, interval between discharge and readmission, and interval between initial injury and date of surgery and last follow-up. The cohort was divided into patients with complete resolution of their aSDH, and patients who needed surgery due to chronification. Results A total of 75 conservatively treated patients with aSDH were included. A chronification was observed in 24 cases (32%). The process of chronification takes an average of 18 days (range: 10–98 days). The following factors were significantly associated with the process of chronification: age (p = 0.001), anticoagulant medication (acetylsalicylic acid [ASA], Coumadin, and novel anticoagulants [NOACs]) before injury (p = 0.026), administration of procoagulants (p = 0.001), presence of other coagulopathies such as thrombocytopenia (p = 0.002), low hematoma density at discharge (p = 0.001), hematoma thickness on admission and discharge (p = 0.001), and the degree of MLS (p = 0.044). Conclusion Chronification occurred in a third of all patients with conservatively treated aSDH, on average within 3 weeks. The probability of developing a cSDH is 0.96 times higher with every yearly increase in age, resulting in 56% chronification in patients ≥ 70 years. Hematoma thickness and impairment of the coagulation system such as anticoagulant medication (ASA, Coumadin, and NOACs) or thrombocytopenia are further risk factors for chronification.

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Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature

Cited by 169 publications

References 84 publications

Long-term excess mortality after chronic subdural hematoma

Long-term excess mortality after chronic subdural hematoma

Predicting Chronic Subdural Hematoma Recurrence and Stroke Outcomes While Withholding Antiplatelet and Anticoagulant Agents

Frequency of and Risk Factors for Chronification in Traumatic Acute Subdural Hematoma following Conservative Therapy

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