Holl Dana C, Volovici Victor, Dirven Clemens M F, Peul Wilco C, van Kooten Fop, Jellema Korné, van der Gaag Niels A, Miah Ishita P, Kho Kuan H, den Hertog Heleen M, Lingsma Hester F, Dammers Ruben
Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands.
Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands; Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands.
World Neurosurg. 2018 Aug;116:402-411.e2. doi: 10.1016/j.wneu.2018.05.037. Epub 2018 May 14.
Chronic subdural hematoma (CSDH) is one of the more frequent pathologic entities in daily neurosurgical practice. Historically, CSDH was considered progressive recurrent bleeding with a traumatic cause. However, recent evidence has suggested a complex intertwined pathway of inflammation, angiogenesis, local coagulopathy, recurrent microbleeds, and exudates. The aim of the present review is to collect existing data on pathophysiology of CSDH to direct further research questions aiming to optimize treatment for the individual patient.
We performed a thorough literature search in PubMed, Ovid, EMBASE, CINAHL, and Google scholar, focusing on any aspect of the pathophysiology and nonsurgical treatment of CSDH.
After a (minor) traumatic event, the dural border cell layer tears, which leads to the extravasation of cerebrospinal fluid and blood in the subdural space. A cascade of inflammation, impaired coagulation, fibrinolysis, and angiogenesis is set in motion. The most commonly used treatment is surgical drainage. However, because of the pathophysiologic mechanisms, the mortality and high morbidity associated with surgical drainage, drug therapy (dexamethasone, atorvastatin, tranexamic acid, or angiotensin-converting enzyme inhibitors) might be a beneficial alternative in many patients with CSDH.
Based on pathophysiologic mechanisms, animal experiments, and small patient studies, medical treatment may play a role in the treatment of CSDH. There is a lack of level I evidence in the nonsurgical treatment of CSDH. Therefore, randomized controlled trials, currently lacking, are needed to assess which treatment is most effective in each individual patient.
慢性硬膜下血肿（CSDH）是日常神经外科实践中较常见的病理实体之一。从历史上看，CSDH被认为是由创伤引起的进行性复发性出血。然而，最近的证据表明，其存在炎症、血管生成、局部凝血功能障碍、复发性微出血和渗出物等复杂交织的途径。本综述的目的是收集有关CSDH病理生理学的现有数据，以指导进一步的研究问题，旨在为个体患者优化治疗方案。
我们在PubMed、Ovid、EMBASE、CINAHL和谷歌学术上进行了全面的文献检索，重点关注CSDH病理生理学和非手术治疗的任何方面。
在发生（轻微）创伤事件后，硬脑膜边界细胞层撕裂，导致脑脊液和血液渗入硬膜下间隙。一系列炎症、凝血功能受损、纤维蛋白溶解和血管生成过程随即启动。最常用的治疗方法是手术引流。然而，由于其病理生理机制，手术引流相关的死亡率和高发病率，药物治疗（地塞米松、阿托伐他汀、氨甲环酸或血管紧张素转换酶抑制剂）在许多CSDH患者中可能是一种有益的替代方法。
基于病理生理机制、动物实验和小型患者研究，药物治疗可能在CSDH的治疗中发挥作用。CSDH的非手术治疗缺乏一级证据。因此，需要进行目前尚缺乏的随机对照试验，以评估哪种治疗方法对每个个体患者最有效。
