Neuro · Vol. 4, No. 1 · 2017 · pp. 16–24 · e-ISSN 2377-1607

Chronic Subdural Haematoma: Systematic Review Highlighting Risk Factors for Recurrent Bleeds

Mohamed Abdelsadg, Avinash Kumar Kanodia, Athar Abbas, Asim Sheikh

Department of Neurosurgery, Ninewells Hospital, Dundee, UKUnited Kingdom
Department of Radiology, Ninewells Hospital, Dundee, UKUnited Kingdom
Department of Neurosurgery, Leeds General Infirmary, Leeds, UKUnited Kingdom

DOI: https://doi.org/10.17140/noj-4-125 · Published 2017-05-16 · Licence: https://creativecommons.org/licenses/by/4.0 · © 2017 The Author(s)

Also available as PDF (figures and tables appear in the PDF).

Abstract

Introduction : Chronic subdural haematoma (CSDH) is one of the commonest forms of intracranial haemorrhage. Surgical drainage of CSDH is a routine operation in the modern neurosurgical practice which has shown to be the most effective way in treating this entity; however, the incidence of recurrence of the haematoma post operatively remains as high as 26.5%. The risk factors for CSDH recurrence remains an area of ongoing research. Objective : We have conducted a systematic review to evaluate the available literature addressing the risk factors for CSDH recurrence, aiming to minimise or at least identify patients at higher risk of recurrence in order to decrease associated morbidity. Methods : Ovid via Medline, PubMed, and Google scholar databases were searched for eligible studies, search results were then limited to studies in English language, Humans and studies published within the last 5 years. The included studies were critically appraised using the Critical Appraisal Skills Programme (CASP) tool, and each study has then been ranked using the Harbour and Miller hierarchy of ranking. Results : Based on available evidence, we classified the risk factors associated with recurrence to patients’, radiological, and surgical factors. Patient factors include history of seizures, trauma, alcoholism, brain atrophy, and presence of CSF shunts, while the role of diabetes in relation to the recurrence is controversial. Radiologically the presence of air in the subdural space post-operatively, the width of the haematoma, and the presence of bilateral CSDHs are associated with increased risk of recurrence. While the predictive value of multiple membranes in the CSDH remains controversial. Surgically, the risk of recurrence was noted to be higher in patients with parietal or occipital compared to those who had frontal burr hole drainage, also placing a subdural drain decreases the chance of recurrence and some evidence showed better outcomes for frontally placed drains. The role of anti-inflammatory agents (including steroids) remains an area of ongoing debate. Conclusions : Risk factors for CSDH can be divided into patients’, radiological, and surgical factors. We encourage health care providers to minimize if not prevent potentially avoidable factors. Patients with increased risks for recurrence should be identified early by the treating team and when possible should be informed about their higher than usual risk of recurrence. Moreover this review highlights the general lack of a sufficiently.

Keywords: Chronic subdural haematoma; Recurrence; Bur hole drainage; Outcome

Conclusion

The review highlights the lack of unified definition for CSDH recurrence as different studies use different methods in labelling recurrence; nonetheless the majority combine clinical features as well as imaging modalities to identify recurrence of CSDH. The 20,35 available evidence is generally underpowered and more research is required in this topic.

There are different factors contributing to the recurrence of CSDH, which can be divided into patient factors, radiological factors, surgical/technical factors, and post-operative factors.

Patient factors include history of seizures, trauma, alcoholism, brain atrophy, and presence of CSF shunts, while there is conflicting evidence regarding the role of DM in relation to recurrence risk of CSDH.

Radiological factors include presence of air in the subdural space in the post-operative scan, width of the haematoma, width of the subdural space and presence of bilateral CSDH. The predictive value of presence of multiple membranes in the

CSDH remains controversial.

With regards to the surgical factors, there are different techniques adopted, nonetheless it was found that burr hole craniotomy is the most adopted method, and there is lack of evidence testing outcomes of other surgical techniques. The risk of CSDH recurrence is higher in patients with parietal or occipital drainage compared to those who had frontal burr hole drainage. Placing a subdural drain was noted to decrease the chance of recurrence and some evidence showed better outcomes for frontally placed drains.

Post-operative patient positioning seems to affect the recurrence risk, with the current evidence promoting avoidance of early sitting up of patients with CSDH. It is clearly noted that more studies are necessary to address this topic.

The role of anti-inflammatory agents (including steroids) remains an area of hot debate. There is a need of well conducted adequately powered multicentre randomised trial(s) to increase our understanding and deliver more robust recommendation regarding the topic .

Finally, we have briefly described the factors thought to be associated with increased risk of recurrent CSDH and highlighted areas of ongoing debate.

Conflicts Of Interest

The authors declare that they have no conflicts of interst.

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