Soleman Jehuda, Nocera Fabio, Mariani Luigi
Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.
Swiss Med Wkly. 2017 Jan 17;147:w14398. doi: 10.57187/smw.2017.14398. eCollection 2017.
Chronic subdural haematoma (cSDH), one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year 2030, owing to the continuous aging of the population. Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations. We provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. "Wait and watch" or "wait and scan" management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, our knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treat-ment of cSDH.
慢性硬膜下血肿（cSDH）是最常见的神经外科疾病之一，通常发生于老年患者。由于人口持续老龄化，预计到2030年其发病率将翻倍。手术通常是首选治疗方法，但在某些情况下保守治疗可能是一个不错的选择。我们对分析cSDH保守治疗方案和自然史的研究进行了系统综述。在筛选的231篇文章中，35篇被纳入本系统综述。评估cSDH自然史和保守治疗方式的研究仍然较少，且主要证据级别较低。cSDH的自然史仍不明确，仅在病例报告或非常小的病例系列中进行了分析。对于无症状或症状轻微的患者（Markwalder评分0 - 1），建议采用“观察等待”或“观察并扫描”管理。然而，似乎没有明确的临床或影像学征象表明cSDH是否会自发消退（C级推荐）。对于症状未加重或未处于昏迷状态的有症状患者，口服类固醇治疗可能是手术的替代方案（C级推荐）。氨甲环酸在一个小患者系列中被证明有效（C级推荐），但其在接受抗血栓或抗凝药物治疗的患者中增加血栓栓塞事件的风险尚不清楚。血管紧张素转换酶抑制剂仅作为手术的辅助治疗进行了评估，其对复发率的影响仍存在争议。甘露醇在小型回顾性系列研究中显示出有前景的结果，可能是一种有效的治疗方式（C级推荐）。然而，治疗持续时间长是一个主要缺点。对于无轻瘫表现的患者，可以使用血小板活化因子受体拮抗剂进行治疗（C级推荐），因为它们似乎能促进血肿消退，尤其是在计算机断层扫描显示有积液或低密度血肿的患者中。最后，阿托伐他汀似乎是无症状或轻度症状性cSDH患者保守治疗的安全选择（C级推荐）。总之，我们对cSDH保守治疗方式的了解较少，且基于小病例系列和低级别证据。然而，即使对于有大血肿的有症状患者，一些治疗方式似乎也很有前景。目前正在进行随机对照试验，有望为我们提供支持或反对cSDH保守治疗的充分证据。
