Chronic Subdural Hematoma (CSH) is Still an Important Clinical Problem. Analysis of 700 Consecutive Patients

Abstract Background Chronic subdural hematoma (CSH) is still an important neurosurgical problem and the number of patients increases despite the progress in early diagnosis of cerebral lesions. Methodology We analyzed a group of 700 consecutive patients treated in neurosurgical departments for CSH. Clinical state on admission was evaluated according to the Markwalder scale, all patients had CT studies and were operated using craniotomy or burr holes with closed system drainage techniques. Results More than 50% had extensive intracranial bleeding, almost half of the patients were treated with oral anticoagulants. The patients with extensive fresh bleeding were in significantly worse states on admission and were treated by craniotomy and external capsulectomy (42%). All the others had burr holes and closed system drainage of the subdural space. Results of treatment were acceptable, 2% died, and 1.5% remained vegetative, due to massive hemorrhage and severe neurological deficits on admission. Conclusions Despite a progress in diagnosis, CSH still remains an often cause of severe intracranial complications. The rising number of occurrences of this lesion is strictly connected with a wide use of oral anticoagulants. Surgical removal of CSH still remains the best type of treatment for such lesions.


Introduction
Chronic subdural hematoma (CSH) is defined as encapsulated hematoma having an outer and inner membrane [1,2]. This kind of hematoma occurs mainly in older populations, and if not treated surgically leads to death [3,4]. In many patients CSH is slowly developing after mild head trauma, however the number of patients with no trauma history is rising, probably due to anticoagulant therapy [3,[5][6][7].
In this paper we analyzed results of surgical treatment of CSH.

Results
On admission 126 patients (18%) were comatose, and 392 patients (56%) presented severe neurological deficit which developed within 0 to 7 days before admission. The patients with fresh bleeding into the hematoma cavity were significantly clinically worse than patients with hypodense subdural lesion. Extensive fresh bleeding was noted in 294 patients (42%) and all these patients were treated by craniotomy with external capsulectomy. The patients with fresh bleeding received oral anticoagulants significantly more frequently. Table 2   Abstract Background: Chronic subdural hematoma (CSH) is still an important neurosurgical problem and the number of patients increases despite the progress in early diagnosis of cerebral lesions. Methodology: We analyzed a group of 700 consecutive patients treated in neurosurgical departments for CSH. Clinical state on admission was evaluated according to the Markwalder scale, all patients had CT studies and were operated using craniotomy or burr holes with closed system drainage techniques. Results: More than 50% had extensive intracranial bleeding, almost half of the patients were treated with oral anticoagulants. The patients with extensive fresh bleeding were in significantly worse states on admission and were treated by craniotomy and external capsulectomy (42%). All the others had burr holes and closed system drainage of the subdural space. Results of treatment were acceptable, 2% died, and 1.5% remained vegetative, due to massive hemorrhage and severe neurological deficits on admission. Conclusions: Despite a progress in diagnosis, CSH still remains an often cause of severe intracranial complications. The rising number of occurrences of this lesion is strictly connected with a wide use of oral anticoagulants. Surgical removal of CSH still remains the best type of treatment for such lesions. intracerebral [12] as well as subdural [4][5][6][7].
Minimal repeated hemorrhages slowly leads to the development of CSH, and in many patients such course of illness is complicated by extensive subdural hemorrhage even causing brain herniation [6]. Burr holes or twist drill craniostomy followed by closed system drainage of subdural space is a method of choice in the treatment of this lesion [2,9,13]. We used it in all patients with no CT signs of severe fresh bleeding. However 42% of patients required craniotomy due to large subdural deposit of fresh blood and significant intracranial shift. These patients were clinically significantly worse than patients with no extensive fresh bleeding.
Despite the fact that 74% of patients on admission presented severe neurological  The number of recurrences was acceptable -3.5% required repeated surgery. All patients had control CT 3 to 5 days after initial surgery, however it does not seem necessary [14], and control CT should be performed only in patients, whose clinical status worsens after initial surgical treatment. In 73 (10.5%) patients control CT showed significant pneumocephalus, however no one patient presented clinical symptoms or required surgical treatment due to this complication.
In all patients, CT performed during the first week after surgery shows blood deposit in the subdural space, but it does not require any intervention. If the patient improves clinically no procedures should be performed. Bilateral hematomas were noted in 3.5%, however all these patients were in good clinical condition and were treated with bilateral burr holes [15].