Department of Neurological Surgery, Columbia University, College of Physicians & Surgeons, 710 West 168th Street, New York, NY 10032, USA.
Neurosurg Rev. 2012 Apr;35(2):155-69; discussion 169. doi: 10.1007/s10143-011-0349-y. Epub 2011 Sep 10.
Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.
慢性硬脑膜下血肿（cSDH）是一种日益常见的神经疾病。尽管 cSDH 广泛流行，但在其临床管理的许多方面仍缺乏共识。我们概述了 cSDH 的流行病学和病理生理学，并讨论了几个有争议的管理问题，包括术后抗凝药物恢复的时间、抗癫痫预防的有效性、cSDH 清除后的活动方案，以及各种手术清除技术的比较效果。通过 2010 年 10 月 19 日在 PubMed 上进行了搜索，使用了以下关键词：“硬膜下血肿”、“开颅术”、“颅骨钻孔术”、“管理”、“抗凝”、“癫痫预防”、“抗血小板”、“动员”和“手术清除”，单独和组合使用。确定了相关文章，并回溯引用以获得更多的论文。然后对比较各种 cSDH 清除方法的疗效和并发症的荟萃分析进行了分析。一般认为，有明显凝血功能障碍的患者应迅速纠正。尽管预防静脉血栓形成的逐步恢复抗凝方案可能来自其他神经外科手术的指南，但需要进一步的前瞻性研究来确定在最近引流的 cSDH 情况下重新开始全剂量抗凝的最佳时间。也有证据表明，cSDH 患者需要预防癫痫，但现有的文献支持对癫痫风险较高的患者进行预防。关于 cSDH 手术技术的已发表数据支持对高危手术患者床边进行原发性扭转钻头颅骨钻孔术（TDC）引流，对于有明显膜的 cSDH 患者，开颅术是一线清除技术。需要更大规模的前瞻性研究来解决这些 cSDH 管理方面的问题，以建立明确的建议。
