Our next speaker is joining us from Nigeria, Dr. Ohegbulam. He will be speaking on a topic that I think is truly global now, which is the enigma of chronic subdural hematomas. Thank you very much. I wish to thank the organizers and the WNS for the opportunity to say a few words on this problem. Chronic subdural hematoma is a real problem. I regard it as the bread and butter of neurosurgery in the sense that any resident who comes into the program, the day he drains a chronic subdural hematoma, and that patient who probably was gradually deteriorating by the time he was admitted with anesthesia, and then he does this borehole, drains it, and the patient wakes up right in front of him. I think the impression is so lasting in his memory that throughout his training he will never forget that experience. I always feel that patients who recover from chronic subdural hematoma are the most dreadful patients any neurosurgeon would encounter. All those cases that take us hours in the theater with the operating microscope and so on, they don't give us that satisfaction, the satisfaction that chronic subdural hematoma does give. It is unfortunate that we don't really attach much importance to this fairly common disease, but very, very important. The traumatic, mild traumatic brain injury often leads to chronic subdural hematoma, and we should always remember that. How do we define this? This is just a collection of blood in the subdural space, as we know, and gradually a membrane is formed. CT appearance is what we see, and MRI would look like this. It's a common problem, and antecedent trauma is majority of cases present, but sometimes not recognized by the patient. Entering the car bumps the head repeatedly several times, particularly in elderly patients. This could ultimately lead to chronic subdural, but the patient may not be aware of that trauma. Over the centuries, the concept of what is chronic subdural hematoma has changed. In the Stone Age, they regarded it as black evil. In the 17th century, it was taken as stroke. In the 19th century, it's thought to be an inflammatory disease. More recently, traumatic lesions were almost always ascribed to this. Currently, the thinking is changing to the fact that it may be a degenerative process. Classification is based on the duration post-trauma, since most of them are due to trauma, and it's only when they exceed three weeks that we regard them as chronic subdural. Age relationship is very important, and we see that later in this. Brain atrophic predisposes to a developmental subdural hematoma. The pathogenesis is thought to be due to torn bridging veins, and this progresses to incise because of brain atrophy. Then a complex pathogenesis ensues with membrane formation, repeat hemorrhages due to neocapillary networks that are present. Also, it's been suggested that there may be three stages in this process as part of the pathological process, which I think we all know about now. How frequent is this condition? This is really difficult because in developing countries like ours, it's very difficult to know the true frequency of subdural hematoma. It is thought to be up to 5%, but in people over 70 years of age, it can be as high as 7%. It's interesting that in a recent literature search in 2015, 2,593 articles were seen to be published in chronic subdural hematoma. Three centers worked in over a five-year period. I'm just giving samples to give us an idea about the frequency of this condition. They reported about 1,254 cases. The largest series we have read in the literature from Japan captured over 63,000 patients. In the African continent, a Google search listed only a few scholarly articles on chronic subdural hematoma, a statement that was made by a previous speaker that where the problems exist, they are not often reported. In my center, over a 10-year period or 15-year period, we only recorded about 32 cases. But in the pre-CT era in Zimbabwe, 11, only reported 11 cases over a three-year period. The difference that CT has made in the diagnosis of this condition. The causes are often common or unusual. In the common causes, trauma, whether major or minor, are often blamed. The unusual causes are many, and we see this mostly in case reports in the literature. So many conditions have been implicated associated with chronic subdural, as this list would demonstrate. In our center, I will give three unusual cases which should remind us that we should always search for an underlying, particularly when subdural hematomas occur. Sometimes there may be an underlying pathology. One of them is a lymphocytic leukemia, which was associated with chronic subdural. It was recognized at first, and then when it recurred, a more search was made. It was found to be the underlying cause. A case of cancer of the prostate that led to repeated recurrence of chronic subdural. And another cancer case, the primary could not be found, that also came as a simple chronic subdural, it was drained, and when it recurred, then greater search revealed the changes in the skull. In these cases, maybe the recurrence may be due to a dural metastasis. It could be due to platelet dysfunction, or it could be a coagulation problem. And those are typical cases. The diagnostic imaging in the pre-CT era in geography was, of course, when I started neurosurgery, I diagnosed chronic subdural with angiography. And you can imagine how many must have been missed. Then we progressed to a period of CT and MRI, which has led to better prognosis and the management of these cases. An anatomical location of chronic subdural is variable, but the frontal parietal is a commoner site, but we shouldn't ignore that sometimes it's interhemispheric, it could be in the posterior fossa, it could also be combined. Treatment is an area that is very controversial, and no standardized, universally accepted treatment is so far on the table. Non-surgical treatment is not uncommon. The physicians like to suggest that surgery is not always necessary in the management of chronic subdural hematoma unless the patient is brought in unconscious. They have a variety of interventions that could help in management of these cases. But for surgery, there are a lot of procedures that are on the table, from borehole to twist drill, needle aspiration, craniotomy, craniotomy with membranectomy, endoscopic drainage, double barrel. It depends on somebody's preference. I personally, my preference is borehole under local anesthesia. I experienced in our center, the 62 cases I mentioned, the median age was 58 years for our patients, very different from what is reported from developed countries and increasingly chronic subdural is found in people over 60, 70 years of age. The etiology in our center was mostly due to trauma. Antiplatelet problem did exacerbate some of the cases. The clinical features, headache is the most common presenting feature, but sometimes patients presented with other complaints. The interval of injury and CT diagnosis of chronic subdural, even though three weeks is the standard, but we have seen cases present two years after the injury. In fact, the record was 60 weeks after the injury. We've seen cases that come with ossification of the chronic subdural. We do, as a routine in our center, we use local anesthesia to do our boreholes for the drainage of subdural, and we find this quite satisfactory. Outcome of the cases we managed, we have a recurrence rate of 7% and a mortality of 6.5% in our center, and this may be because of the younger age of the patients we manage. A major problem, of course, is pneumocephalus with cases who have had drain, because our routine is to do inserted drain, a closed drainage for at least 48 hours and a routine CT scan. Why did I attach the term enigma to chronic subdural hematoma? This is a list of synonyms for the word, and you can see this is a simple disease, but full of problems and lots of controversies. The controversies include surgery or no surgery, how many boreholes are needed for effective drainage, is craniotomy necessary, is anesthesia going to be general or local anesthesia, is drainage necessary, and if drain is needed, for how long would you leave the drain? Should one always do a post-operative CT scan, and should antibiotic coverage be given? We should also bear in mind the mimics of chronic subdural. Dementia, subdural empyema, hygroma, pneumocephalus, epidural hematoma, and in developing countries, malaria. Everything is always diagnosed as malaria unless a CT is done. Many of the patients who come to us have been managed in other centers as cases of malaria until they see them really getting bad, or a relative who is more knowledgeable insists that they should go for a CT scan. Recurrence of chronic subdural is the major challenge in the management of this condition. Recurrence is defined as the reaccumulation of hematoma post-operatively in the same cavity from where you drained it, sometimes contralateral, within three months of the evacuation of the hematoma. And then, of course, reappearance of the symptoms. The average recurrence rate is about 16 percent, and the range in the literature is between 8 to 39 percent. And the consequences, of course, include costs to the patient, particularly in countries where there's no health insurance. A lot of studies have gone into this recurrence. How do you prevent recurrence of chronic surgery? And a lot of factors have been blamed, places that bilateral chronic surgery is an independent predictor, antiplatelet or anticoagulation as factors that lead to recurrence. These are, of course, accepted. Train the position of the patient post-operatively. Should you train the patient in supine position or tilted up? Does this have an influence on the recurrence rate? Dysphasia, the separated chronic surgery in post-operative CT scan, no drainage inserted, basal position of the chronic surgery hematoma, hematoma content itself, and the drainage position are all factors that have been associated with recurrence. Surgical approach, whether the drainage should be bilateral or unilateral, I mean, whether the borehole should be single or multiple, these have made no difference in the recurrence rate in some studies quoted there. Irrigation of the intraoperative cavity has given inconsistent results. Duration of drainage recurrence is high, if less than 24 hours, 72 hours. So from this, as you can see, there's so much uncertainty. MRI has been used to determine whether it can influence the decision on when to anticipate recurrence or not. TW1 motility measures was found to be useful in predicting the propensity of chronic surgery to recur, and more so in cases of closed drainage. The best catheter position for chronic surgery, occipital drainage, had a higher rate of chronic surgery hematoma recurrence, and a much increased rate of pneumocephalus. Now what are the potential risks of chronic surgery? It is thought that a good recovery is possible in up to 89% of cases. In 8.4% of cases, according to the study by Murray, no clinical change really occurred, and patient worsened in 2.2% of cases. And they had a mortality of 1.2%. But other studies have different opinions on this. But in general, old age is a strong predictor of outcome in chronic subdural hematoma. In the Japanese series, which I referred to earlier, of 65,000 cases, the commonest age was the ninth decade, people over 80 years of age. And 30% of them needed help at time of discharge. And an amazing 40% of those patients over 90 years of age could not even go back to their home. They had to be looked after in a hospital or a home, a nursing home. And they conclude that chronic subdural prognosis may no longer be as good as it was thought to be. And this implication of this is quite serious, because the most countries, the population is aging. And that means that the risk of chronic subdural is going to be on the increase, and the prognosis is going to get worse and worse. You can imagine what this means to healthcare delivery in most countries. In Africa, our predicament is even worse. There's high level of poverty, very few neurosurgeons, misdiagnosis, particularly by non-neurosurgeons, because the patients go to clinics and all sorts of places before they reach a center that has a neurosurgical service. There's no health insurance virtually, at most 5% coverage in a country like Nigeria. So most people out-of-pocket expenses for healthcare is the norm. And when that is the case, people are very reluctant, when they have a headache or sort of complaints, minor complaints that chronic subdural induces, they don't rush to hospital to seek for CT scan. The impact of social determinants are quite serious, and they may impact very seriously on the morbidity of chronic subdural. We therefore feel that chronic subdural is perhaps the commonest condition in neurosurgical practice. And every neurosurgeon, and particularly residents, needs to master this disease. There are large volumes of publications on the subject, controversies are still very much bound. Outcome is still good, but with the increasingly aging population, it's going to deteriorate. Mimics and unusual cases confuse the picture. There is not much level one or level two evidence to guide management. And our cities are very, very scarce in this disease so far, and cause for food for thought. For Africa, the possible solution is that health insurance should be really advocated. And public education and awareness on chronic subdural hematoma should increase. Doctors should, neurosurgeons should try very hard to get the message so that patients should be suspected of having subdural when they have these basic complaints, headache, and neurological symptoms start appearing. We need help from international organizations, including the WNS, CNS, CANS, WFNS, and WHO, which is why I am using this to conclude my talk, to invite you to Abuja in July, when the African neurosurgeons will be gathering to discuss the problem of neurosurgery in the continent, and the help of international neurosurgery community will be appreciated. So please, put the dates in your diary. Thank you very much. Questions? What did you want? Peter. So there's quite a lot of interest in using steroids for the treatment of chronic subdurals. Is that an option? Those patients who may not be suitable or not have access to a neurosurgeon? I'm sure that physicians are doing that. They are using it when they can't get the patients or when they don't even, I would suspect that those patients who go on steroids are put on steroids even before any scan is done, because when patients have complaints and they assume that they have stroke or something, they put them on steroids. But anybody who has actually gone to hospital and been subjected to a CT scan, which diagnosed chronic subdural hematoma, I would personally not use steroids for the management. But I don't know whether other colleagues believe in that or not. Unless it's a small subdural, but I don't usually, I would not put them on steroids. I want to thank you for the overview of a very important topic, not just for developing countries, but for the entire world, and your words about mastering the diagnosis and management of this disease entity are very important, especially for the residents. I think you pointed out the variation in treatment patterns, but one thing that seems to have some pretty good support in the literature, and we have one of the authors in the audience, there was a study that was published in 2017 out of Cambridge, a randomized controlled trial of drain versus no drain. Peter, you were co-author on that paper, and it was small numbers, but very conclusive that you should use a drain, no matter what you do, you should probably put a drain. Now, the questions that you raised about how long should you put the drain in, what kind of drain, where to put it, those things still, I think, are valid areas for investigation. Yes. That paper's been confirmed in a subsequent audit, so I think the drain is important. Well, we do agree that the drain is very important. In our circumstances in Africa and in Egypt and in the underdeveloped world, the presence of the drain might subject the patient to the risk of infection, which might be catastrophic. What we do back home is that we do what's called subgaleal drain, where we create a pocket in the subgaleal space and let the drain drain to it, and then it is absorbed from there, rather than using an external drain, which is very risky in our circumstances. In our center, we drain routinely. All our sub-bureaus, I think, unless I missed a point, but it is a routine to drain for at least 48 hours, and we do a CT scan before the drain is removed. That is our protocol. Jamie. Hi. Thank you for that talk. This is an extremely important entity that we all treat a lot of, and it's just actually one of the more difficult entities that we do treat, and we actually do have a fair experience using steroids, almost as first-line management, and then we are actually working to experiment with using tranexamic acid that's been used as sort of an off-label usage for that drug. So there is a role potentially for medical management, even of ones that are causing mass effect, without significant neurological deterioration that would require. In fact, I've even treated steroids in patients that have had coagulopathies due to leukemia or other diseases with primarily steroids that have had good results. So it's hard for me to know, and we have to obviously collect the series of these patients, and it's been written about, but we have to find out exactly which subtype of patients might benefit the most from medical management versus surgical management. I think that's still very much up in the air. So you're supporting controlled studies, randomized controlled trials? No, there really hasn't been. There are some trials out on clinicaltrials.gov on tranexamic acid, and we're actually working on a protocol now with that. But it's mostly anecdotal, unfortunately, but it's not to say that there is not that option out there in order to treat non-surgically, especially in difficult patients or patients that might not be good surgical candidates. But we do have a trial that's ongoing. It's a randomization to steroids versus placebo in patients who have coagulopathies or those who have not had surgery. It may help answer that. Three of your patients so far. Thank you.

chronic subdural hematoma

neurosurgery

trauma

diagnostic process

treatment options

public awareness