Introduction: Current management strategies of chronic subdural hematomas (CSDHs) remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques. Therefore, we undertook a systematic review and meta-analyses to examine the efficacy and safety of multiple treatment modalities.
Methods: We searched several databases for studies evaluating percutaneous twist-drill bedside drainage, single or multiple burr holes, craniotomy, corticosteroids (main or adjuvant therapy), use of drains, irrigation, bed rest, and treatment of recurrences. Mortality, morbidity, cure, and recurrence rates were examined for each variable. Randomized, prospective, retrospective, and all observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model.
Results: A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized and the remaining 234 were observational. We included our unpublished single-center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR 0.69, 95% CI 0.46–1.05, P=0.09), morbidity (RR 0.45, 95% CI 0.2–1.01, P=0.05), cure (RR 1.05, 95% CI 0.98–1.11, P=0.15), and recurrence rates (RR 1, 95% CI 0.66–1.52, P=0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR 1.97, 95% CI 1.54–2.45, P=0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR 0.46, 95% CI 0.27–0.76, P=0.002). Craniotomy was associated with higher morbidity if considered initially (RR 1.39, 95% CI 1.04–1.74, P=0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR 0.22, 95% CI 0.05–0.85, P=0.003).
Conclusions: Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.
Patient Care: The meta-analyses yielded several findings. The main finding is the equal evidence of safety and efficacy obtained from percutaneous bedside drainage compared to the operating room burr hole management of chronic subdural hematomas (the most commonly used and preferred treatment method as per previously published surveys). These findings may result in a change in practice, as they are obtained from a high level of evidence and reported based on recent methodological guidelines. We believe that these findings may result in potential cost savings related to operative theater resources and involvement of multiple health professionals and may eliminate the perioperative risks associated with general anesthesia for a fragile group of patients. Moreover, multiple outcomes and findings were reported for several management options at variable levels of evidence in addition to recommendations for future research.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of choosing a safe and effective management option for chronic subdural hematoma patients. Moreover, to realize the potential health cost savings, without compromising patients care, associated with considering bedside procedures . 2) Discuss, in small groups, the outcomes related to variable treatment modalities of chronic subdural hematomas. 3) Identify an effective and safe treatment option for chronic subdural hematoma patients.