Chronic Subdural Haematoma in the Elderly
Chronic subdural haematoma (CSDH) is a common condition in the elderly neurosurgical population. It is thought to result from a combination of head trauma followed by an inflammatory reaction in the subdural space surrounding the brain. This results in th
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Ellie Edlmann, Peter J. Hutchinson, and Angelos G. Kolias
20.1 Introduction Chronic subdural haematoma (CSDH) is one of the most common conditions a neurosurgeon will come across in the elderly population. The reason for this can be said no better than by Markwalder’s words in 1981, “…a disease of older age, in which physiological brain atrophy, frequent head trauma and coagulation disorders...or alcoholic hepatopathy play a cumulative role” [40]. This has become increasingly true, with an aging population and a new generation of anticoagulant drugs being used for wider indications. A CSDH is essentially a collection of blood and blood breakdown products in the subdural space, between the layers of the arachnoid and dura mater (Fig. 20.1). Although it is occasionally considered a rather “benign” condition, it shouldn’t be forgotten that left untreated, symptomatic CSDHs will lead to a poor outcome in most instances [40]. This is either directly through haematoma enlargement and cerebral decompensation or the inevitable complications such as pneumonia, venous thromboembolism, etc. Ensuring that treatment is efficacious and timely is important in order to minimise the morbidity and mortality associated with this condition. In this chapter, we intend to assess the background pathophysiology, interventions and outcomes that are reported in the literature to date. However, it is important to first recognise that the CSDH literature has some limitations. Although there are meta-analyses, these have a paucity of level 1 evidence, and there are currently only 13 published prospective randomised controlled trials in the field [34]. However, it is an ever-expanding topic area, and now 20 prospective randomised clinical trials
E. Edlmann • P.J. Hutchinson • A.G. Kolias (*) Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital & University of Cambridge, Cambridge, UK e-mail: [email protected] © Springer International Publishing Switzerland 2017 M. Berhouma, P. Krolak-Salmon (eds.), Brain and Spine Surgery in the Elderly, DOI 10.1007/978-3-319-40232-1_20
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E. Edlmann et al. Area of underlying compressed brain Subarachnoid space surrounding brain, containing CSF Chronic subdural haematoma contained within membranous capsule Outer layer of dura mater
Fig. 20.1 Schematic representation of a CSDH along the left cerebral convexity (right) and comparative CT head scan (left)
are registered on the WHO-ICTRP website. There is also a problem with the literature using wide-ranging and heterogeneous baseline data and outcomes in CSDH [12, 13]. Core outcome sets have been recommended as a method of increasing congruency of reported outcomes, making published data more comparable and the compilation of systematic reviews easier. This review has therefore tried to use data from meta-analyses, larger studies or those that are well conducted and/or with findings of high relevance/interest.
20.2 Epidemiology CSDH is well described as being a disease of the elderly and large reviews have
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