Improving treatment for chronic subdural hematoma

This thesis investigates the efficacy of different treatment strategies for chronic subdural hematoma (cSDH). Chapter one serves as an introduction to the subject. The first part focuses on conservative therapy (wait-and-watch) in patients with no, or only mild symptoms. The existing literature was systematically reviewed to determine the success rate of conservative therapy (avoidance of surgery) and additionally the success rate of conservative therapy and factors associated with it were evaluated in a retrospective cohort study. The success rate was approximately 60-66% and a hypodense hematoma was associated with success. The second part examines which treatment modality —conservative or surgical therapy— offers the most effective treatment for certain cSDH patients. First, the association of initial treatment strategy with clinical outcomes, conservative vs. surgical therapy, was evaluated in a cohort study by using propensity score methods. Conservative treatment was associated with fewer complications and had shorter hospital stay after adjusting for clinical and radiological baseline differences. Second, we evaluated the operative approach in patients with bilateral cSDH, comparing unilateral versus bilateral surgical procedures. Initial unilateral surgery was associated with less complications, had a similar duration of hospital stay and reoperation and mortality rates. The third part of this thesis focuses solely on surgical therapy. First, the literature was systematically reviewed to determine recurrence following the predominant surgical approach, namely burr-hole craniostomy coupled with postoperative drainage, yielding rates between 11.2% and 12.8%. Finally, the influence of surgical timing on clinical outcomes was subsequently examined, revealing no effect of timing on outcomes.