Med Pregl 2020; LXXIII (9-10): 295-300. Novi Sad: septembar-oktobar.

295

REVIEW ARTICLES
PREGLEDNI ČLANCI
Clinical Centre of Vojvodina, Center of Radiology, Novi Sad1 Review article
University of Novi Sad, Faculty of Medicine Novi Sad2 Pregledni članci
UDK 616.831-001-073.7:616-036.8
[Link]

CHRONIC SUBDURAL HEMATOMA – DIAGNOSIS, TREATMENT AND

PERSPECTIVES

HRONIČNI SUBDURALNI HEMATOM – DIJAGNOZA, LEČENJE I PERSPEKTIVE

Mirela JUKOVIĆ1, 2 and Viktor TILL1, 2

Summary Sažetak
Introduction. Chronic subdural hematoma has become an important Uvod. Hronični subduralni hematom postaje značajan entitet u
entity in radiological, neurological and neurosurgery practice. Clas- radiološkoj, neurološkoj i neurohirurškoj praksi. Klasifikacija
sification. The classification of chronic subdural hematoma is most subduralnog hematoma se vrši najčešće u odnosu na vreme
often done in relation to the time of the disease onset (acute, subacute nastanka bolesti (akutni, subakutni i hronični) i druga klasifi-
and chronic), whereas the second classification is based on hematoma kacija je zasnovana na denziteu hematoma korišćenjem kompju-
density using computed tomography. Clinical presentation. The terizovane tomografije. Klinička prezentacija može imitirati
clinical presentation may mimic a spectrum of various diseases and različit spektar oboljenja i hronični subduralni hematom se lako
chronic subdural hematoma can be easily overlooked without radio- može prevideti bez radiološke verifikacije. Dijagnoza je delom
logical verification. Diagnosis. The diagnosis of chronic subdural klinička i delom radiološka. Kompjuterizovana tomografija je
hematoma is partly clinical and partly radiological. In most cases, u najvećem broju slučajeva incijalna metoda za dijagnostiku
computed tomography is the initial diagnostic method for detection ovog oboljenja. Mnoge studije ukazuju na različitu strategiju u
of this disease. Many studies point to different management strategies dijagnostici i tretmanu ovog oboljenja. Terapija hroničnog sub-
in the diagnosis and treatment of the disease. Therapy. The therapy duralnog hematoma se sprovodi u odnosu na neurološki deficit
of chronic subdural hematoma depends on the patient’s neurological pacijenta i generalna podela obuhvata konzervativni ili hirurški
deficit, but generally it is divided into conservative and surgical treat- tretman. Cilj ovog rada je revijalni prikaz hroničnog subduralnog
ment. Conclusion. The aim of this paper is to review chronic sub- hematoma sa osvrtom na njegove kliničke i radiološke karakte-
dural hematomas with reference to their clinical and radiological ristike zbog boljeg razumevanja ovog fenomena.
characteristics for better understanding of these phenomena. Ključne reči: hronični subduralni hematom; CT; radiologija;
Key words: Hematoma, Subdural, Chronic; Tomography, Spi- dijagnoza; znaci i simptomi; ishod lečenja; ocena težine traume
ral Computed; Radiology; Diagnosis; Signs and Symptoms;
Treatment Outcome; Trauma Severity Indices

Introduction Depending on the timing of presentation and symp-

toms duration, subdural hematomas are classified as
Subdural hematomas are extra axial, semilunar acute (to 7 days after trauma), subacute (8 - 22 days)
accumulations of blood located between the dura and and chronic type (over 22 days after injury) [3]. This
arachnoid. They are caused by stretching of very thin type of classification was made without clear criteria
cortical bridging veins because of acceleration/de- and consensus in literature [4]. Another classification
celeration forces [1]. There are several hypotheses of subdural hematomas was made based on the texture
and data in literature that explain formation and pro- of the hematoma on plain computed tomography (CT)
gression of chronic subdural hematoma (CSDH) such scan as hyperdense, mixed, isodense and hypodense
as inflammatory process, bridging vein trauma, os- [5] (Figure 1. 1.1. - 1.6). The CSDHs mostly occur in
motic pressure gaps, conversion of acute subdural the elderly whose number is increasing every year. The
hematoma to CSDH, and membrane neovasculariza- index of demographic aging in 2010, in the North part
tion in the subdural space [2]. of Serbia (Vojvodina Province) was 1.06, according to
Petrović et al. 2011 [6]. As the population is aging rap-

Corresponding Author: Dr Mirela Juković, Univerzitet u Novom Sadu, Medicinski fakultet, KCV – Centar za radiologiju,
21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: [Link]@[Link]
296 Juković M, et al. Chronic Subdural Hematoma

Abbreviations for better understanding of these phenomena in order

CSDH – chronic subdural hematoma to improve diagnosis, therapy and clinical outcome.
CT – computed tomography
GCS – Glasgow coma scale Radiological classification of CSDHs
GOS – Glasgow outcome scale
MRI – magnetic resonance imaging The CSDHs may mimic various neurological dis-
MLS – midline shifts eases. When we are dealing with elderly patients with
HW – hematoma width CSDH, sometimes it cannot be recognized by clini-
DTI – diffusion tensor imaging cians alone, because many symptoms and signs in
patients may be consequences of atherosclerotic
changes and degenerative brain diseases, so CSDH
can be overlooked without additional radiological
diagnosis [10]. Classification of CSDH was made by
Nakaguchi et al. based on internal architecture, den-
sity, and hematoma expansion on CT [11]. However,
density of the hematoma on brain CT is not strictly
connected to older age, namely, hyperdense hematoma
on CT is usually acute, but isodense hematoma is not
only subacute, and hypodense is not strictly chronic
[5]. Acute subdural hematomas are usually caused by
traumatic events, but CSDHs can appear without pre-
vious trauma (in 30 – 50% of patients) [12]. The CS-
DHs may be unilateral and bilateral with the assump-
tion that the cranial morphology plays an important
role in determination of the site [13, 14]. Potentially,
repeated hemorrhage is connected to different density
of the subdural hematoma on CT, and it depends on
Figure 1. Classification of subdural hematomas (SDH) coagulation status and other risk factors and comor-
1: Hyperdense subdural hematoma on the right side; 2: Uni- bidity in older patients. Extravasation of blood and
lateral isodense CSDH on the right side; 3: Unilateral iso- cerebrospinal fluid into the subdural space causes lo-
dense CSDH on the left side; 4: Hypodense CSDH on the cal aseptic inflammation and inflammatory induced
left side; 5: Unilateral mixed density of CSDH on the left angiogenesis. Consequently, dura mater produces
side; 6: Mixed bilateral CSDH granulation tissues and inflammatory cells leading to
Slika 1. Klasifikacija subduralnog hematoma (SDH) neomembrane production i.e. the capsule of the he-
1: Hiperdenzni subduralni hematom sa desne strane; 2: matoma [15]. Fibrinolytic activities cause microhem-
Jednostrani izodenzni hronična subduralni hematom orrhage and increase the subdural hematoma [16].
(HSDH) sa desne strane; 3: Jednostrani izodenzni HSDH
sa leve strane; 4: Hipodenzni HSDH sa leve strane; 5: Jed- Clinical features
nostrani HSDH mešovitog denziteta sa leve strane; 6: Bi-
lateralni HSDH mešovitog denziteta The clinical course of this type of disease includes
three phases: initial phase, which includes formation
idly, according to the literature [7] it is more likely to of subdural hematoma presenting with several symp-
expect an increasing incidence rate of CSDH in this toms and episodes; the second phase involves biochem-
popullation. Consequently, a higher incidence of mor- ical mechanisms of subdural hematoma growth with
tality is possible if the prevention, diagnosis and treat- clinically asymptomatic period (or latent period) lasting
ment strategies are not improved as well. Prevention of from a few days to several weeks; and the third phase
CSDH includes reduction of falls and traumatic injuries with expanding hematoma and disturbance of compen-
and future research should be directed towards preven- satory mechanism which leads to symptomatic period
tion and identification of intrinsic and extrinsic risk of the disease [2]. Also, the interval from trauma to
factors for falls in elderly people [8]. Optimal therapy clinical presentation of CSDH is different in younger
and constant monitoring are recommended for patients and older patients. Younger patients may have promot-
with comorbidities such as alcohol consumption, co- ing factors for CSDHs such as ventriculoperitoneal
agulopathy, liver and kidney diseases and seizures with shunts, intracranial hypotension, and history of coagu-
clinical reference to older patients with sudden neuro- lopathy, alcohol consumption, vascular malformation
logical deficit, behavioral disorders and mental chang- or arachnoid cyst and have shorter duration from trau-
es. The reduction of postoperative complications in ma to surgery treatment [17, 18]. Delayed clinical pres-
hospitals is also important and patients need special entation of CSDH in elderly occurs due to wideness of
nursing care. Nursing knowledge, and practice about extra axial liquor spaces, as a result of cortical atrophy
care of patients with CSDH should be improved [17, 19]. The literature data show numerous different
through educational and training programs [9]. symptoms and signs in patient with CSDH [10]. In the
The aim of this paper is to review CSDHs with ref- thesis of Juković, which included 83 patients with CS-
erence to their clinical and radiological characteristics DHs treated at the Clinical Center of Vojvodina in
Med Pregl 2020; LXXIII (9-10): 295-300. Novi Sad: septembar-oktobar. 297

the period of three years, the following symptoms The newest techniques, such as MR, MR spec-
were found: headache, dizziness, seizures, vomiting, troscopy, MR perfusion, diffusion tensor imaging
hemiparesis, mental changes, confusion, speech and (DTI) and 18F-fluorodeoxyglucose positron emis-
visual disturbances or facial paresis. According to sion tomography have an important role in the di-
Juković, the highest percentage of patients with agnosis of traumatic brain injuries. Although not all
CSDH in Vojvodina had comorbidities such as high of these techniques are routinely implemented in
blood pressure (33%) and heart diseases (16%). Al- daily radiological practice, their relevance is grow-
cohol consumption was recorded in 16.9% of pa- ing, and they are given importance due to the pos-
tients and coagulability disorders in 13.2%. A previ- sibility of individual approach to each patient and
ous trauma was found in 67.5% of patients, but thus better diagnosis and treatment [31–33].
32.5% of patients had no traumatic event, or they did
not remember prior head injury [13]. Falls and fall- Therapy
induced injuries are the most important injuries in
elderly people and represent one of the major causes The treatment of subdural hematoma depends
of disability and morbidity and about 20% need on the type of hematoma and clinical presentation.
medical attention [20]. Acute subdural hematoma is more common in
On admission, Glasgow Coma Scale (GCS) is the younger patients and requires urgent treatment be-
most widely used scoring system used in assessing cause of brain edema, existence of MLSs diagnosed
level of consciousness and neurological deficit [21]. by CT and more severe clinical symptoms and
The patient’s clinical outcome is based on Glasgow signs. The CSDH requires prompt surgical treat-
Outcome Scale (GOS) [22]. Although the history of ment in cases of significant neurological deficit,
trauma is the major cause of subdural hematoma, after the latent period has passed. Surgical treat-
non-traumatic subdural hematomas can be diagnosed ment of CSDH includes different principles of
after lumbar puncture causing intracranial hypoten- evacuation (Figure 2) such as one or two burr hole
sion, after long term usage of antiplatelet or antico- drainage, twist drill craniotomy, craniotomy and
agulant drugs or due to coagulation disorders [23]. the subdural evacuating port system [34, 35].
Santarius et al. showed that burr hole is the supe-
Diagnosis rior method than twist drill craniotomy [36]. Pa-
tients that were treated with burr hole had lower risk
Computed tomography and magnetic resonance for recurrence of hematoma and small percentage
imaging (MRI) play an important role in the diagno- of complications after surgery [36, 37]. Craniotomy
sis of subdural hematoma. The MRI has a higher sen- is a more invasive method and it requires an ex-
sitivity for evaluation of internal structure and ne- tended time of surgery and recovery period [38].
omembrane of CSDH that is important for optimal According to Juković, the average hospital stay of
surgery treatment [23]. As a rapid, non-invasive and patients who were treated with craniotomy was 13.3
widely available method, CT is the first line modality days and in patients treated with burr hole it was
of choice in diagnosis of subdural hemorrhage [24]. about 10 days [13]. In exceptional cases, the surgical
Some dural and leptomeningeal metastases, sarcoido- treatment of patients with CSDH is postponed, al-
sis, histiocitosis and subdural empyema [25, 26] may though there are positive radiological parameters.
mimic or may be associated with CSDHs, therefore If the general clinical status of the patient is poor,
the use of contrast CT is justified in such cases. due to comorbidities (liver disease, chronic pulmo-
In the thesis of Juković, clinical and CT parameters nary obstructive disease, cardiac decompensation)
are used to give more information about the prognosis or there are risk factors for surgical treatment
and outcome of patients with CSDH [13, 17, 27–30]. (thrombocytopenia, coagulation disorder) the sur-
Isolated CT parameters - midline shifts (MLSs) and gery is delayed with constant monitoring [39]. Mori
hematoma width (HW) fail to show a high prognostic and Maeda showed that patients with surgical treat-
value for the outcome. However, MLS and hemiparesis ment had good clinical recovery and that surgical
show a high prognostic value when MLS exceeds the
threshold level [27]. Clinical parameters included the
age of patients and neurological state on hospital ad-
mission evaluated using GCS. The GCS showed to be
most significant for the outcome estimated by GOS.
The combination of these parameters using multiple
regression analysis is used for predicting unknown val-
ues to a certain extent (R2 = 0.33).
GOS = 0.166-0.018 x A+0.013 x W+0.313 x Figure 2. Types of surgical treatment in patients with
GCS+0.040 x MLS CSDHs (single burr hole drainage/left side, two burr
Although only about one third of outcomes can holes drainage, craniotomy/right side)
be explained by the created model, more cases and Slika 2. Tipovi hirurškog tretmana kod pacijenata sa
application of advanced statistical models could HSDH (jedan ovalni trepanacioni drenažni otvor/leva
lead to improved treatment and outcome of patients strana slike; dvostruki ovalni trepanacioni otvor, krani-
with CSDH. otomija/desna strana slike)
298 Juković M, et al. Chronic Subdural Hematoma

therapy is safe even in patients above 90 years if in fast preoperative diagnosis of CSDH as well as in
their clinical and physical condition is appropriate follow-up. The MRI and DTI could be implemented as
[19]. The recurrence of CSDH after surgery is pos- additional imaging techniques, because of detailed eval-
sible and factors that contribute to recurrence of CSDH uation of internal characteristic of CSDH and determin-
are multi-factorial involving independent predictors, ing the significance of mass effect on corticospinal tracts
such as laminar type of hematoma, thicker hematoma, and other brain structures which could be potentially
and larger post-operative drainage amounts of CSDH involved in the manifestation of neurological symptoma-
[23, 40]. Stanišić et al. showed that hematoma volume tology. Clinical signs and symptoms, GCS on admission,
before surgery, laminar and separated types of CSDH biochemical and laboratory analysis, and neuroimaging
and residual CSDH post-surgery on the CT scan were data provide precise information about every patient.
independent predictors for recurrence of CSDH [41]. The clinical and radiological input data about patients
Ohba et al. showed that pneumocephalus after surgery with CSDH may be the basic information for optimal
treatment had a tendency to be associated with recur- strategies in individual clinical treatment protocols. To-
rence of CSDH [42]. Postsurgical complications may day, machine learning techniques, based on computer
be related to tension pneumocephalus, anesthesia, cer- softwares, can optimize protocols and improve patient
ebral inflammation, intraparenchymal hemorrhage or treatment and outcome [51, 52]. The implementation of
neurological deficits, more frequently in recurrent advanced methods for neuroimaging data analysis could
CSDH [43, 44]. contribute to better diagnosis and give overall perform-
In Juković’s research, the postoperative complica- ance of outcome. Literature suggests the use of compu-
tion rate was low. One of the patients had ischemic ter assisted system, which is integrated with a medical
stroke, one had intraparenchymal hemorrhage. Extrac- imaging machine, provides a quick diagnosis and re-
ranial complication in the form of pneumonia was duces the number of diagnostic errors [53]. New techni-
noted in one patient [13]. According to literature cal and statistical methods can be implemented in ra-
records, the data about spontaneous resolution of diological imaging analysis for better detection and ex-
CSDH [39, 45] and nonsurgical treatment are isolated panded diagnosis systems [54].
cases [46, 47]. Asymptomatic patients, mild headache
or patients without neurological deficits are candidates Conclusion
for conservative treatment. It is considered that small
volume of the CSDH without significant mass effect Chronic subdural hematoma is a disease of the
on brain parenchyma, MLS below 5 mm on the CT elderly, but it has a great potential to become one of
scan or frontal localization of CSDH have tendency to the most common diseases in radiological, neuro-
resolve spontaneously. The “wait and see” approach is logical and neurosurgery practice due to the in-
justified in patients with a low volume of CSDH and crease of the aging population. Recognition of this
in patients without neurological deficit [48]. Hemipare- disease is essential for proper treatment and reduc-
sis and speech disturbance in elderly patients with large tion in mortality. Clinical evaluation associated with
midline shifts and unilateral CDSH were most com- radiological imaging allows better understanding
mon signs that required surgery [49]. of this phenomenon providing correct diagnosis and
better prognosis of the patients. We strongly believe
Trends in diagnostic radiology and that a larger sample of patients, together with a com-
clinical outcome of CSDH prehensive database of clinical and radiological
signs evaluated through the prism of modern data
Neuroimaging modalities, supported by computer mining techniques and predictive models, may sig-
technology, are becoming more and more significant in nificantly improve the treatment and final outcome
healthcare [50]. The CT modality has a remarkable role of various types of brain diseases in the future.
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Rad je primljen 28. IX 2020.
Recenziran 1. XII 2020.
Prihvaćen za štampu 1. XII 2020.
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