Subacute subdural hematoma [Neurosurgery Wiki]

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====== Subacute subdural hematoma ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1vgA1aT01vjxwBnSjj6BKek06rK240gb67IDH3E5ioLoGUrsT8/?limit=15&utm_campaign=pubmed-2&fc=20240201073418}}
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Subacute [[subdural hematoma]] (SASDH) is known as the gradual pooling of [[blood]] in the [[subdural space]] that occurs in the period of 4-21 days from the [[head injury]]. Usually, it is caused by trauma. This collection causes compression on the brain which leads to the production of localized neurological manifestations, increased intracranial pressure, or altered level of consciousness.
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Subacute [[subdural hematoma]]s are a poorly individualized nosological entity, often equated clinically to [[chronic subdural hematoma]]s. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. 

see [[Subacute traumatic subdural hematoma]].

===== Retrospective case series =====

A **retrospective case series** involving **five patients** with [[subacute_subdural_hematoma|subacute subdural hematoma]] (sASDH), who were managed conservatively using [[atorvastatin]] and low-dose [[dexamethasone]] without surgical intervention. It also includes a **non-systematic narrative review** of existing literature, lacking formal meta-analytic methodology
((Liu T, Wu C, Jiang W, Liu M, Sha Z, Jiang R. Exploring conservative avenues in subacute subdural hematoma: the potential role of atorvastatin and dexamethasone as lifesaving allies. Chin Neurosurg J. 2025 Apr 2;11(1):7. doi: 10.1186/s41016-025-00393-8. PMID: 40176171.)).

===== Critical Appraisal =====

==== Strengths ====
  * The article raises an important question: can we optimize conservative treatment for sASDH in inoperable patients?
  * A novel hypothesis is proposed, leveraging two commonly available pharmacologic agents.

==== Fatal Flaws ====

=== 1. Sample Size and Selection Bias ===
The study is limited to **five hand-picked cases**, all of whom refused surgery. There is **no control group**, **no randomization**, and **no standardization** in patient selection. This introduces massive **selection bias** and **confounding**, rendering the findings anecdotal at best.

=== 2. Lack of Statistical Power ===
With only five patients, the study is **grossly underpowered** to draw any conclusions on safety or efficacy. Even if all patients improved, the **positive predictive value is negligible**.

=== 3. Absence of Mechanistic Evidence ===
The article alludes vaguely to the "possible mechanisms" of action of atorvastatin and dexamethasone but fails to elaborate with any **molecular, imaging, or biomarker-based support**. The hypothesized synergy is speculative and **not experimentally validated**.

=== 4. Cherry-Picking Literature ===
The review portion pulls from only **six studies** without PRISMA methodology, inclusion/exclusion criteria, or risk-of-bias assessments. This is **not a systematic review** but rather a collection of cherry-picked studies to support a preconceived narrative.

=== 5. Logical Fallacy: Post Hoc Ergo Propter Hoc ===
The authors infer that improvement after administration of atorvastatin and dexamethasone implies causality. This is a classic **post hoc fallacy**. No causation can be inferred from such a weak observational structure.

=== 6. Ethical and Practical Concerns ===
Presenting this treatment strategy without rigorous evidence could **mislead clinicians**, **delay necessary surgery**, or foster **false confidence** in a pharmacological approach for a condition where deterioration can be catastrophic.

===== Bottom Line =====
The article is a speculative and weakly documented case series attempting to repurpose two drugs in the treatment of [[sASDH]]. While the intention is noble, the scientific execution is fundamentally flawed. **No clinical decisions should be influenced by this paper.** What is needed is a properly designed **randomized controlled trial**, not a narrative built on five anecdotal successes.


===== Case report from the HGUA =====

==== Q11755 ====
 

81-year-old male brought in by his daughter due to a fall at home two days ago. He reports feeling disoriented since then, experiencing [[gait instability]], and changes in [[behavior]].

{{:pasted:20240305-110437.png?300}}

Left frontoparietal [[subdural fluid collection]], [[isodense]], with [[hyperdense]] areas related to acute/[[subacute subdural hematoma]]. It has a maximum thickness of 27 mm, causing a mass effect on the brain parenchyma and the ipsilateral ventricular system, which is compressed. It is associated with subfalcine herniation, with a displacement of the midline to the right of approximately 9 mm. 

Postoperative CT Scan

{{:pasted:20240305-111301.png?300}}