الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 148 |  |  |
| | | from | 148 | | |
Abstract
Chronic subdural hematoma (CSDH) is an abnormal collection of liquefied blood degradation underneath the dura matter that may result in brain tissue compression and subsequent neurologic deficit.
CSDH is expected to be increasingly common with our aging population. The average incidence is approximately 13.1 per 100,000 people, but reaches 58 per 100,000 among those who are 70 years of age or older.
Since surgery is effective for removing CSDH and reducing the associated neurological deficits, its application is limited by contraindications, the old age of patients, preexisting comorbidities and there is also the high risk of recurrence. The conservative options for the treatment of CSDH are worth investigating and are demonstrating promising results in well selected patients.
The normal subdural space is maintained by dural border cells that tether the dura to the arachnoid. chronic subdural hematoma is preceded by disruption of this gap, either spontaneously or secondary to trauma. Once this disruption occurs, there are a constellation of events, including an inflammatory process leading to the development of neomembranes in addition to incomplete resorption of the hemorrhage that leads to CSDH formation.
Computed tomography (CT) is the ideal diagnostic test for CSDH which is seen as an extra-axial fluid collection of different densities on CT relative to the brain parenchyma.
Isodense lesions are most commonly found. Secondary to the inflammatory process that occurs, mixed densities are also commonly seen. They are believed to be the result of continuous microbleeding and neomembrane formation. Mixed densities are also seen with acute on chronic traumatic events.
Magnetic resonance imaging (MRI) has been useful in differentiating various ages of CSDHs as well as from other pathologies such as subdural hygroma.
While surgery is effective in eliminating or reducing hematoma size, 27–33% of the patients develop recurrent hematoma and the overall mortality is as high as 24–32% among surgically treated patients with CSDH.
The patient’s age, performance score, medical comorbidities, drugs used, additional risk factors, and the surgeon’s experience all influence the surgical decision. Avoiding repetitive surgery should be the most important goal in the elderly population with comorbid diseases.
Making a joint decision with the other neurosurgeons in the department will be the most appropriate method in the selection of surgical or conservative treatment.
Surgery is associated with infection, bleeding, and seizures. Furthermore, surgery is contraindicated in patients with severe cardiac and pulmonary diseases. Because of these limitations for surgery, the safe and effective nonsurgical treatment based on stimulation of vessel maturation and anti-inflammatory pathways may contribute to the resolution of CSDH and may induce neurologic recovery.
Clinical and radiological classifications are more important and useful for medical treatment protocols as the patient can be classified on admission and appropriate treatment can be planned. Once the conservative option is chosen, the remaining issue appears to be which of the medications to use, its dosage, the duration of treatment, and also the method to measure the drug’s efficacy.
Our study revealed that 616 patients in all articles received medical conservative management of CSDH mean age 70.4 years (± 6.33) of them 468 males (76%) and 148 females (24%).
Improvement of the presenting symptoms of the patients occurred in 477 patients (77.4%) and failure of the conservative management which needed further surgical intervention occurred in 139 patients (22.6%). The mean duration of medical treatment was 7.22 ± 4 weeks.
The most common adverse effects were hyperglycemia which was documented in 40 patients (8.8%) followed by infection in 25 patients (5.5%) then weight gain in 17 patients (3.7%). The most serious was thromboembolism in 6 patients (1.3%) and stroke in one patient (0.2%).
The available results of previous studies suggest that medical treatment with corticosteroids, ACE inhibitors, atorvastatin, tranexamic acid and others in a selected group of patients is a good option as primary treatment or adjuvant for surgical intervention, particularly in patients with co-morbidity.
Atorvastatin appears to be of more convincing benefit by its proven efficacy with few side effects compared to other nonsurgical options. Further prospective studies with larger patient cohorts are needed in order to determine the true value of each drug in the conservative treatment of CSDH.