Chronic subdural hematoma conservative treatment
While surgical evacuation is a common and effective treatment for CSDH, conservative management may be considered in certain cases, especially if the patient is not a suitable candidate for surgery due to various reasons such as age, medical comorbidities, or patient preference.
Conservative treatment for chronic subdural hematoma involves closely monitoring the patient's condition and managing symptoms while allowing the body to gradually reabsorb the hematoma over time. Here are some components of conservative treatment:
Observation and Monitoring: Patients with small, stable hematomas and mild or no symptoms may be monitored closely through regular clinical assessments, including neurological examinations and periodic imaging (such as CT scans or MRI) to check for changes in the hematoma size.
Pain Management: Pain and headache are common symptoms of CSDH. Pain management with over-the-counter or prescription pain medications may be necessary to improve the patient's comfort.
Blood Pressure Management: Hypertension (high blood pressure) can contribute to the growth of a chronic subdural hematoma. Managing blood pressure through lifestyle modifications and, if necessary, medication may be recommended.
Seizure Prophylaxis: Seizures can be a complication of CSDH. In some cases, antiepileptic medications may be prescribed to prevent seizures.
see Chronic subdural hematoma seizure prophylaxis.
Physical and Occupational Therapy: Depending on the patient's symptoms and functional deficits, physical and occupational therapy may be recommended to help improve mobility, strength, and activities of daily living.
Education and Monitoring: Patients and their caregivers should be educated about the signs and symptoms of worsening CSDH, such as severe headache, confusion, weakness, or changes in consciousness. Close monitoring is essential to detect any deterioration promptly.
Nutritional Support: Good nutrition is crucial for the healing process. Adequate intake of nutrients and hydration can support the body's ability to reabsorb the hematoma.
It's important to note that conservative treatment may not be appropriate for all cases of CSDH, and the decision to pursue this approach should be made on a case-by-case basis in consultation with a neurosurgeon or a neurologist. If symptoms worsen or if the hematoma increases in size during conservative management, surgical intervention may become necessary to evacuate the hematoma and alleviate pressure on the brain. Therefore, close monitoring is essential throughout the conservative treatment process, and the treatment plan should be adjusted as needed based on the patient's condition.
Chronic subdural hematoma medical treatment
Steroids
Atorvastatin
Goreisan
Multicenter, Prospective, Randomized Controlled Trials
Chen et al. compared the efficacy of body posture combined with pharmacotherapy and pharmacotherapy alone in the treatment of chronic subdural hematoma(CSDH). Firstly, retrospective case series study was conducted. Thirty cases of CSDH that had received body posture combined with pharmacotherapy at Department of Neurosurgery, Huashan Hospital Affiliated to Fudan University were studied retrospectively. Twenty-seven patients were male, and 3 patients were female. The age of patients (M(IQR)) was 66(16) years (range:28 to 84). Nineteen patients had unilateral hematoma, and 11 patients had bilateral hematoma. All patients received pharmacotherapy and body posture therapy that was to raise their lower limbs 20 to 30 cm with leg lift pad and get abdominal compressed with customized abdominal belt in supine position. Patients were required to maintain the body posture as much as possible, with the maximum to 16-18 hours per day. Patients with unilateral hematoma should tilt the head to the affected side and avoid tilting it to the opposite side. For patients with bilateral hematoma, there was no need for head lateralization. Patient were treated with oral dexamethasone and atorvastatin simultaneously. The preliminary efficacy of body posture combined with pharmacotherapy was determined by hematoma improvement rate which was analyzed by Clopper-Pearson method. Then, the multi-center, prospective, randomized controlled trial had carried out in 9 medical centers. The stratified block randomization method was adopted. Patients were randomized in a ratio of 1∶1 to either receive pharmacotherapy alone(the control group) or body posture combined with pharmacotherapy(the experiment group) for 3 months and followed up for 6 months. Effective treatment was defined as complete absorption of hematoma, or the hematoma volume decreased by more than 10 ml and Markwalder grading scale score had improved by more than 1 point compared to the baseline. The efficacy rate and surgery conversion rate at 3 months and recurrence at 6 months were observed. Comparison between groups was performed with paired sample t test, Mann-Whitney U test, χ2 test, corrected χ2 test, or Fisher exact probability method. Logistic regression was used to compare the effective rate and operation rate between the two groups. In the respective study, 30 patients completed follow-up 13 to 353 days after treatment. At the last follow-up, the incidence of almost complete absorption or significantly absorption of hematoma (hematoma volume was significantly reduced accompanied by symptom improvement) was 93.3%. The 95%CI for the incidence that analyzed by the Clopper-Pearson method was 77.9% to 99.2%. One hundred and six patients were enrolled in the multicenter study. Fifty-five patients underwent body posture combined with pharmacotherapy. The age was 74(17) years (range:26 to 92). Thirty-nine patients were males and 16 were females. Fifty-one patients underwent pharmacotherapy alone. The age was 69(12) years (range:48 to 84). Thirty-seven patients were males and 14 were females. The length of body posture recorded in diary card was (15.7±2.3) hours(range:7.6 to 19.3 hours). The efficacy rate in the body posture combined with pharmacotherapy group and pharmacotherapy alone group were 83.6% (46/55) and 56.9% (29/51), respectively at 3 months. The result of the logistic regression analysis showed that the efficacy of body posture combined with pharmacotherapy group was better than that of pharmacotherapy alone group (OR=3.88,95%CI:1.57 to 9.58,P=0.003). Surgery rate in the body posture combined with pharmacotherapy group and pharmacotherapy alone group were 5.5% (3/55) and 21.6% (11/51) respectively. The result of Logistic regression showed that the pharmacotherapy alone group was more likely to be converted to surgery (OR=0.21,95%CI:0.05 to 0.80, P=0.023). At the 6 months, no recurrence of cases was found in the body posture combined with pharmacotherapy group. However, the recurrence rate of pharmacotherapy alone group was 6.3% (3/48), there was no significant difference between the two groups (P>0.05). Conclusion: The effect of body posture combined with pharmacotherapy for chronic subdural hematoma is better than that of pharmacotherapy alone 1).
Chen et al.’s study provides compelling preliminary evidence that body posture combined with pharmacotherapy improves hematoma absorption and reduces the need for surgery in CSDH patients. However, methodological limitations, including potential biases and lack of long-term data, necessitate further research. A larger, blinded, randomized trial with extended follow-up and objective adherence monitoring would be valuable to confirm these findings and establish this approach as a standard non-surgical treatment option.