The document reviews the management of chronic subdural hematomas (CSDH), detailing historical perspectives and advancements in treatment options, including surgical and non-surgical methods. It highlights the efficacy of various medical treatments like tranexamic acid and dexamethasone along with surgical techniques such as burr hole craniostomy and middle meningeal artery embolization. The findings emphasize the importance of tailoring treatment strategies to the patient's condition, particularly in the elderly, to minimize recurrence and complications.

1. Chronic Sub dural hematoma: current
paradigm in management, (esp
conservative treatment options)
Dr. Mukesh bisht

2. • CSDH was first reported by Johann Jacob Wepfer in 1657 as “delayed
apoplexy.”
• 1857: Virchow described the famous concept of so-called “pachymeningitis
hemorrhagica interna.” He considered that the etiology of CSDH involved inflammation.
• 1883: Hulke reported successful trepanning of a patient with CSDH
• 1914: Trotter described the origin of CSDH as traumatic.
• 1946: Inglis reported the importance of the two layers in CSDH
• 2000 : Mandai reported the middle meningeal artery embolization

4. • The twist drill technique was developed by Cone at the Montreal Neurological Institute around 1940.
However, the original technique was not published.

5. • Worldwide, recurrence requiring repeat surgery occurs in 5%–29%,
• Cofano F, Pesce A, Vercelli G, Mammi M, Massara A, Minardi M, Palmieri M, D'Andrea G, Fronda
C, Lanotte MM, Tartara F, Zenga F, Frati A, Garbossa D. Risk of Recurrence of Chronic Subdural
Hematomas After Surgery: A Multicenter Observational Cohort Study. Front Neurol. 2020 Nov
24;11:560269. doi: 10.3389/fneur.2020.560269. PMID: 33329304; PMCID: PMC7732444.

6. Medical management
• Nonsurgical treatments for CSDH
• Dexamethasone
• Statins
• tranexamic acid (TXA),
• However, suitability and safety unknown , as elderly, given their high
incidence of frailty and their tendency to be prescribed with multiple
medications.

8. • Tranexamic acid inhibit at two stages –
• inhibits inflammatory reaction through Kallikrein
system
• inactivates plasminogen, thereby inhibiting fibrinolytic
activity.
• Etizolam inactivates platelet-activating factor
resulting in inhibition of lipid-mediated
inflammation.
• Atorvastatin is the most potent drug that helps in
angiogenesis without risk of hematoma. A low dose
(20 mg/day) potentiates angiogenesis resulting in
absorption and resolution of CSDH
• Steroids:
• Decrease fibrinolytic activity
• Decrease inflammation
inhibits neomembrane
formation and ingrowth
of neocapillaries

10. Tranexamic acid
• TXA is a synthetic derivative of the amino acid lysine that reversibly
binds to plasminogen at the lysine binding site, preventing the binding
of plasmin to fibrin, thereby subsequent activation and degradation of
fibrin

11. Administration of Tranexamic Acid After Burr Hole Craniotomy Reduced
Postoperative Recurrence of Chronic Subdural Hematoma
Akinori Miyakoshi, MD, et al, Shizuoka Graduate University of Public Health, Shizuoka, Japan;
Department of Neurosurgery, Shizuoka General Hospital, Shizuoka, Japan
Neurosurgery 93(5):p 1160-1167, November 2023.
• OBJECTIVE:To assess the efficacy and safety of postoperative oral administration of TXA after BC for
CSDH among the elderly.
• retrospective cohort study
• TXA prescription of at least 14 days from the index month
• Outcomes
primary outcome : repeat surgery for CSDH recurrence
secondary outcomes :
death
onset of any thrombosis during the observation period

12. • results indicate that administration of TXA after BC for CSDH reduced
the occurrence of repeat surgery without inducing adverse events
such as thrombosis or death.
• incidence of recurrence for the entire study cohort (946 of 6647; 14.2%)
• Some studies also suggest that the risk of seizures may be increased in patients receiving more
than 2 g/day.
• *Murao S, Nakata H, Roberts I, Yamakawa K. Effect of tranexamic acid on thrombotic events and seizures in bleeding
patients: a systematic review and metaanalysis. Crit Care. 2021;25(1):380

13. • s
Kutty RK, Leela SK, Sreemathyamma SB, et al. The outcome of
medical management of chronic subdural hematoma with
tranexamic acid: a prospective observational study. J Stroke
Cerebrovasc Dis. 2020;29(11):10527

15. • RCT
• Proposed addition of TXA 500 mg twice daily
is a safe dosing regime.
• TXA allows a delay in post operative CSDH
recurrence. (36.6 vs 23.3 % at 6 weeks),
• But did not significantly reduce
symptomatic post-operative recurrence
• trial failed to recruit a sufficiently large
number of participants (fewer than half
the predefined sample size),
• the percentage of participants lost to the
follow-up was over 30%.
• Larger RCT required

16. Dexamethasone
• shown to reduce the occurrence of repeat surgery after BC for CSDH
in randomized control trials;
• But has been shown to be a/w deterioration
• It has also been suggested that the adverse effects of dexamethasone
has a negative effect on outcomes
• *Chaturbedi A. The role of dexamethasone in the era of “Dex-CSDH” randomized controlled trial. A
multicenter, prospective study on specific subset of patients with chronic subdural hematoma (CSDH)
treated with dexamethasone alone or surgery

18. NEJM, December 31, 2020
• RCT
• 8 mg twice daily , tapering dose x 2
weeks
• 748 (680) patients
• a favorable outcome was reported in 286
of 341 patients (83.9%) in the
dexamethasone group and in 306 of 339
patients (90.3%) in the placebo group
• Resurgery: 6 of 349 patients (1.7%) in the
dexamethasone group vs 25 of 350
patients (7.1%) in the placebo group

19. NEJM, December 31, 2020
• Patient who underwent surgery ,
treatment with dexamethasone
resulted in fewer favorable outcomes
and more adverse events than placebo
at 6 months, but fewer repeat
operations were performed in the
dexamethasone group

21. • 20 mg of atorvastatin or placebo daily for 8
weeks
• primary outcome was change in hematoma
volume (HV) by computed tomography after
8 weeks of treatment.
• 196 patients
• After 8 weeks, the HV reduction in patients
who were taking atorvastatin was 12.55 mL
more than those taking the placebo (P
= .003)
• 11 (atorvastatin) and 23 (placebo) underwent
surgery during the trial for an enlarging hematoma
and/or a deteriorating clinical condition

22. Atorvastatin
• concerns about the side effects of administering large doses of
atorvastatin to the elderly, who typically have reduced hepatic and
renal function.
• Interaction between atorvastatin and CYP 4A3 is also a concern.

23. SURGICAL OPTIONS
• Burr hole Craniostomy
• Twist drill craniostomy
• Craniotomy
• high recurrence rate : ~ 25.6% in high-risk patients
• the mortality rate for surgically treated patients ranges from 11.1% to 13.5%
• up to 38.4% in patients aged 90 years or older
• Duerinck et al (multicentre prospective randomised trial including 245 patients) found that
burr-hole craniostomy (BHC) leads to the lowest recurrence rate in patients with CSDH

24. (Comparison of Chronic Subdural
Hematoma Treatment [COMPACT]
trial)
• primary end point : reoperation rate
• secondary end points: complication
rates and clinical outcome
• Reoperation rate .
• 7.6% - BHC, 13.1% - MC, and 19.5% - TDC (P
= .07).
• Good outcome
• 78.5% - BHC group, 76.2% - MC, and 69.5% -
TDC (P = .4)
• 6-month outcome similar, BHC offers
the lowest recurrence rate combined
with manageable complication rate
good outcome: when patient did not undergo reoperation, suffered no
surgical or medical complication, and had no related mortality

25. Subperiosteal (SPD) versus
Subdural Drain(SDD) After Burr
Hole Drainage
• studies reported up to September 2019
• Ten studies with 3169 patients
• No significant differences between the
SPD and SDD groups in the favorable
outcomes, Adverse event rates, including
mortality, seizures, and surgical infection,
• However, the use of SPDs was associated
with a lower risk of parenchymal injuries
• Inference: Use of an SPD is safer and
might be more effective

26. • They did not observed any significant differences in mortality or rates
of postoperative complications (infection, pneumocephalus, or
epilepsy) between the SDD and SPGD groups.
• results suggest that the choice of SDD vs. SPGD has no significant
effect on CSDH prognosis, highlighting SPGD as an alternative
treatment option for CSDH

27. Irrigation fluid temperature
• RESULTS: 541 patients, At 6 months after surgery,
• There were 39 of 277 recurrences(14%) requiring reoperation in the RT group,
• 16 of 264 recurrences (6%) in the BT group (P < .001).
• There were no significant differences in mortality, health-related quality of life, or complication
frequency.
• Conclusion: irrigation at body temperature was superior to irrigation at room temperature in
terms of fewer recurrences.
• This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH.
When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered
standard of care.

28. Single vs double burr hole
• Most of the subdural hematomas can be dealt by single burr-hole
drainage
• Nayil K, Altaf R, Shoaib Y, Wani A, Laharwal M, Zahoor A. Chronic subdural hematomas: single or double burr hole-results
of a randomized study. Turk Neurosurg. 2014;24(2):246-8. doi: 10.5137/1019-5149.JTN.8465-13.0. PMID: 24831368.
• Nalin, S. ., Sahu, A. ., Gupta, K. ., & Singh, K. . (2021). Single versus double burr holes evacuation in the treatment of
chronic subdural hematoma: A tertiary centre experience. Romanian Neurosurgery, 35(2), 180–188.
https://doi.org/10.33962/roneuro-2021-028
• D. Sale, Single versus double burr hole for drainage of chronic subdural hematoma: randomized controlled study, World
Neurosurg, 146 (2021), pp. e565-e567
• Belkhair S, Pickett G. One Versus Double Burr Holes for Treating Chronic Subdural Hematoma Meta-Analysis. Canadian
Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 2013;40(1):56-60.
doi:10.1017/S0317167100012956
(metanalysis in 2014)

29. • dBHC seems to be the best modality
for CSDH compared with sBHC and
TDC.
• It showed significantly less
recurrence and reoperation rates
compared with TDC

30. Other surgical methods
• use of a tissue plasminogen activator in addition to TDC
• minimally invasive hematoma evacuation using hollow screws
• subduro-peritoneal shunt in infants , in older patients, and for recurrent cSDH
• small craniotomy and endoscopic hematoma removal
• replacement of the hematoma with oxygen via percutaneous subdural tapping
• carbon dioxide insufflation in addition to BHC and closed-system drainage
• implantation of an ommaya reservoir for repeated punctures and aspiration of
subdural fluid

31. MMA embolization
• case report of refractory chronic
subdural hematoma (CSH) in a 59-
year-old man with coagulopathy
due to liver cirrhosis.
• 3 times burr hole and evacuation ,
followed by ommaya insertion
(which required multiple tapping)
• The patient was successfully
treated by embolization of the
middle meningeal artery after
several drainage procedures Superselective angiograms of the MMA. Left: Early arterial phase.
Center: Late arterial phase.
Right:Capillary phase. A diffuse abnormal vascular network can be seen along the
peripheral area of this artery

33. • RESULTS
• MMA embolization: 98%(in 148 of 151 cases).
• NASH thickness decreased significantly from initial
thickness to 6 weeks, with additional decrease in
thickness observed in both groups at 90 days.
• At longest follow-up, the treated NASHs had stabilized
or improved in 91% and 98% of the elderly and advanced
elderly groups, respectively, with > 50% improvement
seen in > 60% of patients for each group.
• Surgical rescue was necessary in 4.6% and 7.8% of cases,
and the overall mortality was 8.6% and 3.9% for elderly
and advanced elderly patients, respectively.
• CONCLUSIONS
• MMA embolization can be used safely and effectively as
an alternative or adjunctive minimally invasive treatment
for NASHs in elderly and advanced elderly patients
Neurosurg Focus 49 (4):E5, 2020

34. • This propensity-
adjusted analysis
suggests that MMA
embolization for
cSDH is associated
with a greater extent
of hematoma
volume reduction
with fewer treatment
failures than
conventional therapy

37. Morphological changes in chronic subdural hematomas following upfront middle meningeal
artery embolization: sequence, timing, and association with outcomes
MirHojjat Khorasanizadeh et al, Neurosurgical Service, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston;
J Neurosurg 137:235–248, 2022
• They aimed to classify and describe baseline morphological characteristics of the hematomas, delineate
the changes during the course of follow-up
• Retrospective (2018 – 2021)
• Example case demonstrating 3D volumetric measurement of hematoma size over the course of follow-
up. This hematoma was undetectable 5 months post procedure (i.e., complete resolution).

38. • For characterization of the structural appearance of the CSDHs,
classification method modified from that proposed by Nakaguchi et
al.,(6 morphological subtypes)
• 1) Homogeneous hypodense
• 2) homogeneous hyper- or isodense hematomas with a homogeneous
density that were hypodense and hyper- or isodense, respectively.
• 3) Laminar hematomas with distinct hyperdense and hypodense
laminar components arranged longitudinally and in parallel along the
inner and outer surfaces of the hematoma.
• 4) Separated/gradation hematomas with hyperdense and hypodense
components, with the hyperdense component located posterior to
the hypodense component. The boundary between the two
components can be distinct (“separated”) or indistinct (“gradated”).
• 5) Trabecular hematomas with septations and membranes within a
hypo or isodense background.
• 6) Acute-on-chronic hematoma with heterogeneous areas of
hyperdensity (i.e., fresh blood) arbitrarily distributed in a background
of nonacute CSDH with one of the abovementioned structural
appearances.

39. • Morphological progression of CSDHs
after MMAE.
• Early stage
• A: Heterogeneous acute-on-chronic bleeding.
• B/C: Homogeneous isodense /hyperdense.
• Intermediate:
• D/E: Gradation/Separated.
• F: Laminar.
• Late
• G: Homogeneous hypodense.
• H: Trabecular.

40. • The mean time to achieve ≥ 50% reduction in volume was 65.3 days.
• Complete resolution (undetectable hematoma) was achieved in 44.4%.
• The overall rescue surgery rate was 9.6% (5 cases), which occurred after a mean of 25.2 days
(median 22 days) post-MMAE.
• Approximately 95% of the cases followed this sequence of changes, and the few cases that did not
were all associated with eventual hematoma expansion, treatment failure, and the need for
rescue surgery. ‘
• Hematomas with a mean density of < 20 Hounsfield units(HU) at baseline showed a significantly
higher resolution rate (p = 0.038), faster resolution (p = 0.008), better clinical outcome (p = 0.038),
and a trend toward a lower rescue surgery rate (p = 0.09), compared with the HSDHs with a
baseline mean density of ≥ 20 HU .

41. International Stroke Conference (ISC) 2024
• 3 new randomized controlled trials all showing large and significant
benefits of a new embolization process done as an endovascular
procedure, reducing the need for surgery
• Compared with medical therapy alone, the embolization process was
shown to reduce the rate of hematoma progression or recurrence
and/or the need for surgery in patients with smaller subdural
hematomas ,and,
• to reduce the need for repeat surgery in those with larger hematomas
who had undergone initial surgical treatment

42. Embolization of the Middle Meningeal Artery With ONYX™
Liquid Embolic System for Subacute and Chronic Subdural
Hematoma (EMBOLISE) trial
• Active trial (US)
• 10/2020- 08/2024
• Results : December 2020 - August 2023, 400 (of 600)(average age of 72; 27% women)
at 39 centers
• surgery alone vs surgery plus embolization to help reduce the progression or
recurrence of subdural hematoma
• primary outcome : recurrence that required surgical drainage within 90 days
• Resurgery : 4.1% (surgery plus embolization) vs 11.3% (surgery alone)
• neurological dysfunction : comparable -11.9% (surgery plus embolization) vs 9.8%
(surgery alone)
• Serious adverse events attributed to embolization occurred in 2%

43. • Other arms of the EMBOLISE study, which included patients not
undergoing surgery and randomized to either receive the liquid
embolic system or not, are ongoing were not presented at ISC 2024
• main limitation : relatively high loss to follow up.
• dealing with a frail elderly population, especially in the middle of the
pandemic

44. Managing non-acute subdural hematoma using liquid
materials: a Chinese randomized trial of middle
meningeal artery treatment (MAGIC-MT)-protocol
• 03/2021-05/2024
• Enrolled 722 patients across 31
centers in China
• surgery or medical management alone
(control group) or MMA embolization
• primary outcome is the symptomatic
SDH recurrence/progression rate(>3
mm) within 90 ± 14 days

45. • Results :
• Recurrence/progression : 7.2% of the embolization group vs 12.2% of the
control group (P = .02).
• symptomatic subdural hematoma progression occurred in
• 1.9% of the embolization group vs 4.7% of controls (medical mx)
• 4.7% of the embolization group vs 5.2% of controls (surgical)
• Serious adverse events occurred in fewer patients receiving embolization
(6.6%) than in controls (11.6%).

46. STEM Trial (The SQUID Trial for the Embolization of the Middle
Meningeal Artery for Treatment of Chronic Subdural Hematoma)
• 11/2020- 05/2024
• standard therapy (medical management or surgery, which was the control group) or
standard therapy plus embolization with the Squid device)
• primary endpoint : failure of treatment (defined as residual or re-accumulation of the subdural
hematoma (> 10 mm), re-operation (in the surgical group) or surgical rescue (in the nonsurgical group),
or major disabling stroke, myocardial infarction, or death from any cause) within 6 months of
randomization
• primary endpoint : 39.2% (standard management ) vs 15.2% (standard management +
embolization), giving an odds ratio for treatment failure of 3.60 (P = .0001)
• surgical group, 25.4% vs 12.3% (embolization) (odds ratio, 2.4; P = .058).
• nonsurgical arm, 59.2% vs 19.1% (embolization) (odds ratio, 6.1; P = .0001).

47. Discussion
• MMAE is a therapeutic modality for CSDH, especially in patients
• who are high-risk surgical candidates,
• are on a regimen of antiplatelet or anticoagulant medications, or
• have recurrent or refractory CSDHs.
• disadvantage :
• invasive intervention,
• high cost (given the low recurrence rate of CSDH after BC and the lower cost
and high efficacy of nonsurgical treatment)

48. institutional experience:
ENDOVASCULAR MANAGEMENT OF CHRONIC
SUB-DURAL HEMATOMA
Max Institute of Neuroscience Department, MIND, Dehradun

49. INTERVENTION SCENARIOS
• Background diagnosis:
Chronic hemispheric sub-dural hematoma
• Endovascular management
Cerebral angiography and ipsilateral Middle Meningeal artery
embolisation using onyx/glue/ gelfoam

50. CASE 1. Patient with Right FTP SDH with ITP
and thrombocytopenia
45 YR OLF FEMALE PRESENTED TO ER WITH
•HISTORY OF ACCIDENTAL SLIP AND FALL AT HOME
•MODERATE UNILATERAL HEADACHE
•VOMITING 1 EPISODE
•WEAKNESS in LEFT SIDE OF BODY
•CONFUSION
•NO KNOWN CO-MORBIDITIES
•ROUTINE BLOOD INVESTIGATIONS SHOWED
THROMBOCYTOPENIA
•PHYSICIAN CONSULT AND TREATMENT OF ITP STARTED

51. NCCT BRAIN DONE IN ER

52. PATIENT UNDERWENT RIGHT MMA EMBOLISATION IN CATH LAB

53. NCCT BRAIN POST MMA EMBOLISATION

54. CASE 2. LEFT FTP SDH AND INTERHEMISPHERIC
EXTENSION
45 YEAR OLD MALE PRESENTED TO ER
WITH
•H/O TRAUMA
•RIGHT SIDED WEAKNESS
•K/C/O DECOMPENSATED ALCOHOLIC
LIVER DISEASE WITH ASCITES , ICTERUS
•ALTERED CONSCIOUSNESS
--------NCCT BRAIN DONE

55. Left MMA embolisation done.
Post embolisation NCCT brain…..

58. OTHER INDICATION OF DSA

59. • DSA of the right internal carotid artery.
Note the ‘ string of beads ’ appearance
of the right middle cerebral (top arrow)
and internal carotid (middle arrow)
arteries. Also, note an aneurysm of the
extracranial right internal carotid
artery (bottom arrow)

60. MOYA MOYA disease

61. • s

62. •THANK YOU