New horizons in subdural haematoma

Abstract

Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

“…Frequently, older patients with aSDH are observed for 14 days in order to monitor the evolution of aSDH to the chronic type. For symptomatic chronic SDH, the less invasive burr-hole drainage is considered the first-line surgical intervention [100]. Asymptomatic chronic SDH, instead, should be managed conservatively, because the risks exceed the benefits of surgery.…”

Craniectomy versus craniotomy: What can we do for acute subdural hematoma?

“…A better choice may be to wait for 2 weeks to make the hematoma chronic and perform drilling and drainage under the condition of critical monitoring and necessary symptomatic treatment. 14 It seems that brain atrophy in the elderly population provides some space for potential brain swelling. However, there are no RCT studies in the elderly population associated with ASDH surgery to confirm the benefit between craniotomy and decompressive craniotomy.…”

Clinical Outcomes in Elderly Patients with Chronic Subdural Hematoma: Validation of Irrigation Assignment Based on Hematoma Characteristics

“…The increasing incidence of chronic subdural hematoma (CSDH) in elderly patients is a global phenomenon driven by population aging [1]. Additionally, the increased use of antiplatelet and anticoagulant medications has significantly affected CSDH rates over the past few decades [2]. Fall injuries are considered as the most common cause of CSDH, especially in elderly patients [3].…”

“…The incidence of CSDH is currently 2-20 per 100,000 individuals, with a 3-to-1 male-to-female ratio [4]. Projections indicate that by 2030, CSDH will emerge as the predominant cranial neurosurgical condition affecting adults [2]. However, there is limited data regarding the neurosurgical outcomes in aged (≥80 years) patients with CSDH.…”