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1) What kind of disease is chronic subdural hematoma?
Between the skull and brain are three membranes: the dura mater, arachnoid mater, and pia mater. A subdural hematoma is a condition in which blood accumulates on the brain side (below) of the dura mater. Unlike acute subdural hematomas, which are caused by severe head trauma and result in loss of consciousness, chronic subdural hematomas form within a few months (usually around three months) of minor head trauma (for example, falling and hitting the back of the head but quickly getting up). They are more common in middle-aged and elderly people than younger people, and although they are called hematomas, they are often a mixture of blood and water rather than a blood clot. When there are no blood cells present and yellowish water is the primary component, they are called hydrops. They can occur on either one or both sides.
2) What symptoms do you have?
Symptoms such as headache and nausea may be followed by paralysis of the limbs and dementia. Symptoms often appear relatively slowly, but sometimes they can appear suddenly. In elderly people, dementia symptoms such as increased forgetfulness, drowsiness, and decreased spontaneity may also appear.
3) How is the diagnosis made?
First of all, it is important to check whether you have hit your head in the past few months. As mentioned earlier, elderly people may have had a minor head injury that they may not remember very well.
Diagnosis can be made with a head CT or MRI, which clearly shows the brain being compressed by the hematoma.
On CT scans, hematomas often appear whiter than the brain, but they may be slightly darker than the brain or may be mixed in. Because water appears black on CT scans, edema appears black.
4) When is treatment necessary?
If the hematoma grows larger and begins to compress the brain, causing symptoms such as headaches, nausea, and weakness in the arms and legs that makes it difficult to use chopsticks or makes you more likely to trip, surgery is necessary. Even if there are no symptoms in the arms and legs, symptoms such as increased forgetfulness, drowsiness, and loss of initiative, as well as urinary incontinence, may occur. However, these symptoms can also be caused by other illnesses, so a diagnosis of chronic subdural hematoma requires imaging tests such as CT scans.
5) What treatments are available?
Treatments include drug therapy and surgery. Drug therapy may involve the administration of steroids, mannitol, or glycerol. However, the hematoma does not shrink immediately, so treatment may take time and surgery may be necessary in the end. Also, if there are no symptoms, head CT scans may be performed approximately once a month to monitor the progress.
6) How is the surgery performed?
Surgical treatment is superior for the purpose of early relief of symptoms of brain compression. Surgery for chronic subdural hematoma is one of the most frequently performed neurosurgery procedures.
The surgery is often performed under local anesthesia. After shaving, a few centimeters of incision is made in the scalp.
There is a bone under the skin, so a small hole is drilled in it with a special drill, and a small incision is made in the dura mater underneath, allowing the contents of the hematoma to come out. This is then sucked out with a suction tube, and any hematoma that has accumulated further inside is washed away with irrigation water. If necessary, a drain is placed in the hematoma cavity. Depending on the extent of the hematoma, two holes may be made. After this, the wound is sutured closed and the surgery is complete. The time required depends on the extent of the hematoma and whether it is on one side or both sides, but it takes about 1 to 2 hours.
7) When can I be discharged from the hospital after surgery?
A CT scan is performed the day after surgery or on the second day to confirm that the hematoma has disappeared or shrunk, and if a drain is inserted, it is removed. Preventive antibiotic administration is generally continued until the day after surgery. Stitches are removed on the sixth or seventh day, and patients are expected to be discharged around the eighth day. In many cases, symptoms such as disappearance of headaches, difficulty walking, and dementia are improved.
8) How common are complications after surgery? Does it recur?
Postoperative complications are rare, but serious ones include intracerebral hemorrhage, acute subdural hematoma, epidural hematoma, tension pneumocephalus, infection, etc. Complications tend to be more common in elderly patients and those with severe general weakness due to other complications.
The recurrence rate is approximately 8%. Factors that make recurrence more likely include cases with significant cerebral atrophy, low cerebrospinal fluid pressure (in cases with shunt placement), coexisting blood disorders, and coexisting liver disorders. Patients who have suffered frequent head trauma, bilateral cases, are elderly, and have a history of recurrence in the past are also more likely to recur. Furthermore, although extremely rare, cases have been reported in which severe coagulation disorders (DIC) have occurred in patients with coexisting blood disorders, and in patients with a history of cerebral infarction, death has been attributed to recurrent cerebral infarction.
