Pathophysiology of subdural hematomas

Pathophysiology of the development of CSDH

• Clear yellow to dark, thin liquid to semisolid• Gardner 1932,Osmotic gradient theory

– Increase protein content increase oncotic pressure

• Weir– CSDH fluid to be isosmotic to blood and CSF

• Microscopic examination of fluid from CSDHs of any age reveals fresh erythrocytes

• CSDH membrane

Pathophysiology of the development of CSDH

• Neovasculature at outer membrane of CSDH• Abnormal sinusoidal dilate• Both vessel types are composed of endothelial cells• Erythrocytes and platelets found in perivascular

space• Gap junction 8 um leakage of plasma and RBC

into hematoma cavity

Pathophysiology of the development of CSDH

• Kallikrein, bradykinin, and platelet-activating factor (PAF) vasodilatation, increase vascular permeability, prolong the clotting time, release t-PA

• Eosinophil degranulation in the outer membrane fibrinolytic factor, inflammatory mediator local coagulopathy and cell destruction

Evolution of chronic subdural hematomas

Evolution of chronic subdural hematomas

Surgical Treatment ofchronic subdural hematomas

• 1925, Putnam and Cushing : craniotomy with complete removal of the outer membrane and hematoma contents

• 1964, Svien and Gelety : bur hole better outcome than craniotomy (lower reoperation)

• 1977, Tabaddor and Shulmon : study comparing craniotomy had the highest mortality rate

Surgical Treatment ofchronic subdural hematomas

• Suzuki and associates : closed system drainage without irrigation to be as effective as closed system drainage with irrigation

• Smely and coauthors : twist drill drainage without irrigation was superior to bur hole drainage with irrigation

Medical Treatment ofchronic subdural hematomas

• Corticosteroid : decreases leukocyte chemotaxis, inhibits degranulation, inhibit neomembrane formation, prevent clot enlargement

• Bender and Christoff : more rapid neurologic improvement after introducing corticosteroids to the treatment regimen, thereby allowing shorter hospitalization

• ACEI : interrupt neovascularization by inhibiting endothelial vascular growth factor

Medical and Surgical Management

of Chronic Subdural Hematomas

Definition• Fluid collection within the layers of dura matter• DDx : subdural hygroma (subdural hydroma,

external hydrocephalus)• Subdural hygroma can transform into CSDH

Epidemiology• Peak incidence , 80th • Male• Trauma most important risk factor• Postsurgical communication of the subarachnoid

space• CSF shunting• Primart coagulopathy in children• Anticoagulant treatment in adult• Chronic alcoholism

Patient history• No pathognomonic sign and symptoms• Asymptomatic• Coma from increase ICP• Refractory headache• Lack of concentration

Imaging• Preoperative CT scan

– sickle-shaped lesion– midline shift– High risk for recurrence : mixed-density or layer

type

Imaging

• Postoperative CT scan– Recurrence : BHC 29 %, TDC 76 %– Residual fluid : 78% of case on day 10, 15% in

the 6th week– Intracranial air : tension pneumocephalus– Bilateral CSDH : Mount Fuji sign

Imaging• MRI

– Hyperintense on T2 , proton-weightes image– Variability in signal intensity on T1 : 50 %

hyperintense– DDx : Subdural hygroma : Hypointense on

proton-weightes image

Contemporary treatment• Corticosteroid : anti-inflammatory, antiangiogenic• Mannitol• ACEI : antiangiogenic• Anticonvulsant : posttraumatic and postoperative

epilepsy have low incidence in Pt c CSDH• Patient posture after surgey : RDCT,flat position in

the first 3 day after surgery for reduce recurrence• Hydration : increase brain volume• Postoperative hyperemia

Surgical treatment• Gold standard• TDC : up to diameter 5 mm• BHC : 5-30 mm diameter• Craniotomay : larger than 30 mm diameter• Hematoma cavity be filled with 100% Oxygen or

carbon dioxide

Twist drill craniotomy : TDC

• Decompress brain slowly and avoid the presume rapid pressure shift that occur ICH

• 0.5 cm incision• Twist drill hole is place 45 angle,aim direction in

longitudinal axis of the collection• Ventricular catherter insert to subdural space

Surgical treatment

Surgical treatment

• Irrigation : remove hematoma completely

• Drainage :• Recurrence : BHC

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