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A chronic subdural hematoma may present in a computerized axial tomography (CAT) scan with the same density as normal brain tissue. The presence of a lesion may be suggested only by its mass effect. The lack of contrast enhancement or edema may help to differentiate a chronic subdural hematoma for a neoplasm or a cerebrovascular accident.
Eighty three chronic subdural hematomas, obtained by surgery or by necropsy, were examinated. The patient age distribution curve of the non-complicated operative cases showed the highest incidence in the first year of life and also a moderate increase in the elderly group. Recurrent hemorrhage in the walls and in the cavity, was observed in twenty of the seventy three non-complicated cases of chronic subdural hematoma. In five cases the membranes and the subdural sac were invaded by leucemic cells and in the five remaining ones the hematoma was transformed in a subdural empyema. All these complicated subdural hematomas showed evidence of recurrent bleeding, suggesting that the leucemic cells or the infectious agent had spread to the subdural space by this way.
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While unilateral chronic isodense subdural hematomas as a result of indirect signs of a space-occupying lesion are easily recognizable on computed tomography (CT) and clearly diagnosed on the angiogram, bilateral chronic isodense subdural hematomas may cause considerable difficulty. In two cases with CT false negative findings we observed, retrospectively, significant small cellae mediae and also the main part of the anterior horns sharply pointed and approaching one another. Three further cases showed the same ventricular configuration, which we called "hare's ears sign". This sign together with clinical data is always suspicious of chronic bilateral isodense subdural hematomas and carotid angiography is indicated. Other possible signs are: subtle midline shift if the size of the hematoma varies, changed formation of density of brain tissue, non-appearance of cerebral sulci especially in elderly patients, and eventually the visualization of a membrane after intrevenous injection of contrast material.
About 75-80% chronic subdural hematomas give positive results in a brain scan. The typical scintigraphic finding of chronic subdural hematoma is a diffuse widening and increase of the peripheral activity on the anterior view. In the flow studies subdural hematomas lead occasionally to peripheral activity defects. In two cases of chronic subdural hematoma without typical patterns in a perfusion study as well as in static images, we found a displacement of the anterior cerebral vessels as an indircet sign of space occupation.
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BACKGROUND: Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition with persistent challenges related to recurrence. Endoscopic membranectomy (EM) has shown promising results in managing symptomatic non-homogenous (SNH)-CSDH, but comparative evidence against craniotomy with membranectomy (CM) is lacking. OBJECTIVES: To compare the safety and efficacy of EM versus CM in managing SNH-CSDH. MATERIALS AND METHODS: A pilot randomized parallel-group active-controlled open- labeled superiority trial from September 2023 to November 2024 at Government Kilpauk Medical College, Chennai, India. Sixty patients with SNH-CSDH were randomized into EM and CM groups. Recurrence was the primary outcome. Secondary outcomes included operative time, complications, radiological indices, pain, hospital stay, and functional recovery. All patients were followed for six months. RESULTS: No recurrence was observed in either group at six months. Two CM patients required reoperation on postoperative day one ( P = 0.15). EM was associated with shorter operative time ( P = 0.02), lower incidence of post-operative subdural residual fluid ( P = 0.015), better early hematoma reduction/subdural space reduction index ( P = 0.008), midline shift/symmetry improvement index ( P = 0.001), and lesser surgical site swelling ( P < 0.001). All patients were ambulant and had a Glasgow coma scale (GCS) 15 at discharge and at six months (including reoperated patients). Pain scores and functional recovery were comparable. EM patients had shorter hospital stays ( P = 0.004) and no significant complications. CONCLUSION: EM demonstrated favorable early radiological outcomes, fewer complications, and comparable functional recovery and recurrence versus CM in SNH-CSDH. Independent reproduction and larger multicentric trials are needed for validity and generalizability.
INTRODUCTION: Chronic subdural hematoma (cSDH) is increasingly prevalent among older adults due to population aging and widespread antithrombotic use. Although burr-hole drainage remains the standard treatment, recurrence rates are substantial. Middle meningeal artery embolization (MMAE) has emerged as an adjunctive strategy to disrupt dural neovascularization and prevent rebleeding. OBJECTIVES: To assess the efficacy and safety of MMAE combined with standard therapy versus standard therapy alone, with stratification by timing of intervention. METHODS: Randomized controlled trials (RCTs) were searched in PubMed, Scopus, and Cochrane Central up to July 2025. Adults with confirmed cSDH were included. The primary outcome was hematoma recurrence or persistence. Secondary outcomes were reoperation, hematoma resorption, serious adverse events, neurological death, mortality, functional independence, and hospital stay. Risk of bias was assessed with RoB-2, and analyses followed PRISMA guidelines (PROSPERO CRD420251112841). RESULTS: Seven RCTs (1,889 patients) were included. Compared with standard therapy, MMAE significantly reduced recurrent or residual cSDH (RR 0.63; 95% CI 0.46-0.85) and reoperation (RR 0.39; 95% CI 0.28-0.56) without increasing serious adverse events (RR 0.87; 95% CI 0.72-1.06), neurological death, mortality, or poor functional outcomes. Hematoma resorption did not differ significantly. Subgroup and sensitivity analyses confirmed the robustness of the results across age, intervention timing, and follow-up duration. CONCLUSION: MMAE combined with standard therapy significantly reduces recurrence and reoperation in cSDH without increasing adverse events or mortality. Benefits appear independent of procedural timing, though larger RCTs with extended follow-up are warranted to define long-term outcomes and optimal use.
BACKGROUND: Randomized trials suggest that adjunctive middle meningeal artery embolization (MMAE) may reduce recurrence in chronic subdural hematoma (CSDH), but potential sources of variability in treatment effects across studies remain poorly understood. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of MMAE and to explore potential study-level sources of between-study heterogeneity. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials comparing MMAE plus surgery versus surgery alone, following PRISMA guidelines. Trial sequential analysis (TSA) was prespecified to assess the robustness of pooled findings. Exploratory mixed-effects meta-regression was performed to examine whether aggregate study-level mean age and anticoagulation use were associated with variability in recurrence outcomes. RESULTS: Eight trials including 1961 patients were analyzed. MMAE plus surgery was associated with a reduction in recurrence compared with surgery alone (RR 0.63, 95% CI 0.46-0.85; I² = 0%), and TSA supported this finding. Although conventional meta-analysis suggested a reduction in reoperation, the TSA findings were more sensitive to analytical assumptions and less robust. Exploratory study-level meta-regression analyses suggested possible associations between recurrence outcomes and mean age or anticoagulation use, although these findings should be interpreted as hypothesis-generating only. Safety outcomes were comparable between groups. CONCLUSIONS: Adjunctive MMAE was associated with reduced recurrence in CSDH. Exploratory analyses evaluating aggregate study-level characteristics were limited by the small number of included trials and the use of aggregate-level data, and should be considered hypothesis-generating only. Further prospective studies are needed to better understand variability in treatment effects.
CT findings of 46 patients with operatively confirmed chronic subdural hematomas are reviewed. The analysis of the EMI scans resulted in three different types of CT findings. Type 1 is characterized by decreased attenuation of the hematoma contents compared to brain tissue. The hematoma is visualized as a lens-shaped low density area between the skull and the surface of the brain. Type 2 apart from low density areas contains zones of increased attenuation due to recent bleeding into a watery chronic subdural hematoma. In many cases sedimentation causes a well-defined horizontal borderline between the thin fluid parts in the anterior portion and the blood debris in the posterior portion of the hematoma sac. Type 3 shows the same average absorption values as normal brain tissue, a direct visualization is not possible. However , the presence of a midline displacement in combination with ventricular compression and absence of a circumscript lesion even after contrast enhancement, allows the diagnosis of a unilateral chronic subdural hematoma in these cases too. Bilateral chronic subdural hematomas may cause considerable diagnostic difficulties if only one or none of the hematomas is visualized. A relatively small midline displacement points to a second bleeding on the opposite side. Most frequent were hematomas of type 1 (37%), type 2 and 3 could be observed in 30,5% resp. 32,5% of cases respectively.
Three cases of chronic subdural hematoma developing after direct aneurysmal surgery were presented. All patients were males and heavy drinkers. There was no history of head injury after craniotomy. In two of the three cases, the angiography was performed on the 12th postoperative day. An avascular area was already revealed on the postoperative angiograms, but there were no disorders at that time. The intervals between the aneurysmal surgery and the onset of symptoms of chronic subdural hematoma ranged from about two to three months. In this report, the diagnostic criteria for the chronic subdural hematoma resulted from intracranial surgery were also discussed with a consideration on the pathogenesis of this condition.
The urinary estrogen value in 30 cases with chronic subdural hematoma have been assayed before treatment, and also in 16 cases after recovery. Very often the value of estrogen was higher in these patients than the normal range. The relationships between the high estrogen value and the cause of chronic subdural hematoma are discussed.
The authors describe studies performed on material aspirated from chronic subdural hematomas. Patients were given 51Cr-labeled red cells prior to aspiration, and it was possible to demonstrate that the mean daily hemorrhage into the hematoma space amounted to 10.2% of its volume. Immunoelectrophoresis of the aspirated hematoma fluid by monospecific anti-human fibrinogen revealed the presence of fibrin and fibrinogen degradation products that, measured by hemagglutination-inhibition immunoassay techniques, varied between 5.0 and 10,500 mug/ml with an average of 2604 mug/ml in 18 cases. The tissue activator was demonstrated by Todd's histological localization in the outer membrane of the chronic subdural hematoma in 11 cases, but not in the inner membrane. These results indicate that if a clot in the subdural space causes the formation of neomembrane, and excessive fibrinolysis occurs, the subdural clot would not only liquefy, but also enlarge by continuous hemorrhage from the neomembrane. Therefore, local hyperfibrinolysis and continuous bleeding are important in the etiology of the chronic subdural hematoma.
Examination of 15 patients with tumors of the brain in whom the presence of subdural hematomas could not be excluded and of 27 patients with chronic subdural hematomas revealed that displacement of the M-echo was 8 +/- 0.43 mm on the average in chronic subdural hematomas and 5.6 +/- 0.43 mm in tumors. EEG abnormalities were observed in 100% of cases with tumors and were mostly of a coarse character. In chronic subdural hematomas EEG abnormalities were relatively rare (18.5%) and were less manifested than those in tumors. The statistical significance of the differences evidently allows the sign of the dissociation of the EEG and Echo-EG data in chronic subdural hematomas to be used for the differentiation of the disease from tumors.
Chronic collections of fluid in the subdural spaces may result from trauma or may complicate meningitis. The etiological factor, or factors, which contribute to chronicity of subdural fluid in children remains obscure. We postulate that one possible mechanism is the progressive stretching and narrowing of the cortical veins, bridging the subarachnoid and subdural spaces to enter the superior sagittal sinus. This process ultimately leads to thrombosis of these 'hanging veins'. Narrowing and angulation of these veins could result in elevated back pressure favoring the formation of a transudate. 16 children who had progressive and persistent collections of xanthochromic fluid in the subdural spaces secondary to trauma or infection who were treated previously either with subdural tap, burr holes, subdural peritoneal shunt, craniotomy, stripping of membranes and/or a combination of these, were treated by lowering and advancing the superior sagittal sinus with its overlying sagittal suture and performing a duraplasty. This new surgical technique is directed to improve venous drainage from the superior anastomotic vein into the superior sagittal sinus. Angiographic follow-up showed that only 2 patients still have evidence of fluid collection: the rest of the patients showed normal arterial phases, the medullary system was minimally filled and all of these showed remarkable improvement of the venous drainage throughout the superficial cortical veins with no evidence of hanging veins. Intellectual development of these children following lowering of the superior sagittal sinus showed that 8 patients (50%) were normal or above normal; 5 patients (31.2%) were retarded and 3 patients (18.7%) were borderline.
Two cases of relapsing juvenile chronic subdural hematoma with late relapse in adult life are presented and the literature reviewed. Both patients contracted subdural hematoma early in life; its persistence resulted in characteristic skull deformitites. The patients led an asymptomatic life until a second head trauma caused rebleeding into the old hematoma sac with recurring symptoms and signs. The source of rebleeding is the outer subdural membrane. Radiographic features vary, depending on the location and size of the subdural hematoma. The significance of localized thickening of the cranium is stressed in refining the differential diagnosis.
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The authors describe a simple spinal needle trephination technique found to be effective in the treatment of patients with chronic subdural hematomas.