Subdural hematomas develop due to an osmotic gradient that increases protein content and oncotic pressure in the hematoma fluid. Microscopic examination shows fresh erythrocytes in CSDH fluid of any age. Neovasculature and abnormal dilated sinusoids in the outer CSDH membrane allow leakage of plasma and red blood cells into the hematoma cavity. Various surgical techniques are used to treat CSDHs including burr hole drainage, twist drill craniotomy, and craniotomy. Medical treatments like corticosteroids may help reduce recurrence by inhibiting neomembrane formation and inflammation. Postoperative care includes hydration and keeping patients flat to prevent recurrence in the first few days after

1. Pathophysiology
of subdural hematomas

2. Pathophysiology of
the development of CSDH
• Clear yellow to dark, thin liquid to semisolid
• Gardner 1932,Osmotic gradient theory
– Increase protein content  increase oncotic
pressure
• Weir
– CSDH fluid to be isosmotic to blood and CSF
• Microscopic examination of fluid from CSDHs of
any age reveals fresh erythrocytes
• CSDH membrane

3. Pathophysiology of
the development of CSDH
• Neovasculature at outer membrane of CSDH
• Abnormal sinusoidal dilate
• Both vessel types are composed of
endothelial cells
• Erythrocytes and platelets found in perivascular
space
• Gap junction 8 um  leakage of plasma and RBC
into hematoma cavity

4. Pathophysiology of
the development of CSDH
• Kallikrein, bradykinin, and platelet-activating factor
(PAF)  vasodilatation, increase vascular
permeability, prolong the clotting time, release t-PA
• Eosinophil degranulation in the outer membrane 
fibrinolytic factor, inflammatory mediator  local
coagulopathy and cell destruction

5. Evolution of
chronic subdural hematomas

6. Evolution of
chronic subdural hematomas

7. Surgical Treatment of
chronic subdural hematomas
• 1925, Putnam and Cushing : craniotomy with
complete removal of the outer membrane and
hematoma contents
• 1964, Svien and Gelety : bur hole better outcome
than craniotomy (lower reoperation)
• 1977, Tabaddor and Shulmon : study comparing 
craniotomy had the highest mortality rate

8. Surgical Treatment of
chronic subdural hematomas
• Suzuki and associates : closed system drainage
without irrigation to be as effective as closed system
drainage with irrigation
• Smely and coauthors : twist drill drainage without
irrigation was superior to bur hole drainage with
irrigation

9. Medical Treatment of
chronic subdural hematomas
• Corticosteroid : decreases leukocyte chemotaxis,
inhibits degranulation, inhibit neomembrane
formation, prevent clot enlargement
• Bender and Christoff : more rapid neurologic
improvement after introducing corticosteroids to the
treatment regimen, thereby allowing shorter
hospitalization
• ACEI : interrupt neovascularization by inhibiting
endothelial vascular growth factor

10. Medical and Surgical Management
of Chronic Subdural Hematomas

11. Definition
• Fluid collection within the layers of dura matter
• DDx : subdural hygroma (subdural hydroma,
external hydrocephalus)
• Subdural hygroma can transform into CSDH

12. Epidemiology
• Peak incidence , 80th
• Male
• Trauma most important risk factor
• Postsurgical communication of the subarachnoid
space
• CSF shunting
• Primart coagulopathy in children
• Anticoagulant treatment in adult
• Chronic alcoholism

13. Patient history
• No pathognomonic sign and symptoms
• Asymptomatic
• Coma from increase ICP
• Refractory headache
• Lack of concentration

14. Imaging
• Preoperative CT scan
– sickle-shaped lesion
– midline shift
– High risk for recurrence : mixed-density or layer
type

15. Imaging
• Postoperative CT scan
– Recurrence : BHC 29 %, TDC 76 %
– Residual fluid : 78% of case on day 10, 15% in
the 6th
week
– Intracranial air : tension pneumocephalus
– Bilateral CSDH : Mount Fuji sign

16. Imaging
• MRI
– Hyperintense on T2 , proton-weightes image
– Variability in signal intensity on T1 : 50 %
hyperintense
– DDx : Subdural hygroma : Hypointense on
proton-weightes image

17. Contemporary treatment
• Corticosteroid : anti-inflammatory, antiangiogenic
• Mannitol
• ACEI : antiangiogenic
• Anticonvulsant : posttraumatic and postoperative
epilepsy have low incidence in Pt c CSDH
• Patient posture after surgey : RDCT,flat position in
the first 3 day after surgery for reduce recurrence
• Hydration : increase brain volume
• Postoperative hyperemia

18. Surgical treatment
• Gold standard
• TDC : up to diameter 5 mm
• BHC : 5-30 mm diameter
• Craniotomay : larger than 30 mm diameter
• Hematoma cavity be filled with 100% Oxygen or
carbon dioxide

19. Twist drill craniotomy : TDC
• Decompress brain slowly and avoid the presume
rapid pressure shift that occur  ICH
• 0.5 cm incision
• Twist drill hole is place 45 angle,aim direction in
longitudinal axis of the collection
• Ventricular catherter insert to subdural space

20. Surgical treatment

21. Surgical treatment
• Irrigation : remove
hematoma completely
• Drainage :
• Recurrence : BHC

22. Thank you