Clinical Report: Outcomes of Conservative Management in Chronic Subdural Hematoma

Overview

This retrospective cohort study evaluated outcomes in patients with chronic subdural hematoma (CSDH) managed conservatively versus surgically. Conservative management, defined as watch-and-wait without adjunctive therapy, showed a success rate consistent with prior literature, highlighting its role in select patient populations. Key baseline characteristics, radiological features, and survival outcomes were analyzed to identify predictors of progression and prognosis.

Background

Chronic subdural hematoma (CSDH) is a common neurosurgical condition characterized by blood and fluid accumulation between the dura and arachnoid. It predominantly affects elderly patients, with incidence rising due to aging populations and increased anticoagulant use. Diagnosis is primarily via CT imaging, which can show variable hematoma densities. Management depends on symptom severity and hematoma size, with surgery indicated for symptomatic large collections but associated with risks and recurrence. Conservative management is often employed for asymptomatic or mildly symptomatic patients or those unfit for surgery, yet data on outcomes remain limited.

Data Highlights

Key Findings

• Conservative management was applied to patients who were asymptomatic, mildly symptomatic, or unfit for surgery, using a watch-and-wait approach without adjunctive therapy.
• Baseline characteristics such as higher frailty scores (CFS ≥6) and comorbidities influenced the decision for conservative management.
• Radiological assessment included hematoma laterality, density, maximum depth, and midline shift, but predictive factors for progression remain inconclusive.
• Conservative management success rate approximates 66%, consistent with prior systematic reviews.
• Surgical management carries risks including infection, seizures, pneumocephalus, neurological deficits, and a 9–14% recurrence rate.
• Survival data were collected up to two years, with age-adjusted mortality comparisons performed between groups.

Clinical Implications

Conservative management is a viable option for select CSDH patients, particularly those with mild or no symptoms and higher frailty, avoiding surgical risks. Careful baseline clinical and radiological assessment is essential to identify patients suitable for watch-and-wait strategies. Ongoing monitoring remains important given the potential for progression and the lack of consensus on predictive radiological markers.

Conclusion

This study reinforces that conservative management can be effective in appropriately selected CSDH patients, though further research is needed to clarify predictors of progression and optimize patient selection. Understanding patient frailty and radiological features is critical to guide management decisions.

References

1. Foppen et al. 2023 -- Systematic Review on Conservative Management of CSDH
2. General Neurosurgical Literature -- CSDH Diagnosis and Management