Treatment of subdural hematomas in infants

has a long and storied history. In Donald D. Matson’s classic text, there was an extensive discussion of this topic that included descriptions of the invasive procedures needed to make this diagnosis at a time when few imaging data were available; an unforgettable illustration from the text was a photograph showing tubes draining subdural fluid, which was tapped over time at the bedside to follow the progression of the SDH’s content. It is now understood that removing the xanthochromic fluid through punctures, drains, or subduroperitoneal shunts can eliminate subdural fluid collections. Most practitioners consider placement of a shunt as the last resort of many treatment options, because the placement of a shunt generally implies that the condition’s treatment will be lifelong. However, in their article in this issue of the Journal of Neurosurgery: Pediatrics, Kurschel and colleagues suggest that there is a very high likelihood of success in treating subdural fluid collections with the placement of a unilateral, valveless subduroperitoneal shunt, and they further indicate that such systems can be safely removed after the fluid collections have been evacuated. Because many of the concerns about treating subdural collections during infancy through shunts result from comparison with the use of ventriculoperitoneal shunts for hydrocephalus, a few differences should be stressed. The most important is that the treatment of subdural collections and the treatment of hydrocephalus have vastly different end points: elimination of the subdurals in the former and control of the hydrocephalus in the latter. This difference may be the reason that using a valveless shunt system works so well in the hands of the authors: when the fluid collection is completely gone, flow stops because there is no longer any fluid to flow through the system, and one hopes that there is permanent occlusion of the tubing. Thus, the authors of this study systematically removed virtually all of the catheters, a maneuver tolerated by their patients without problems. The most important point of this paper is that in this particular group of patients, removal of the shunt system can be done apparently with impunity. The protocol recommended for these patients, which does not distinguish between fluid collections following nonaccidental trauma and those collections from other causes, appears to be a reasonable course for the treatment of children with subdural fluid collections. We have had personal experience with patients who have undergone subdural fluid shunt treatment in the past who developed late symptoms, indicating that they were dependent on their subdural shunts; it is to be hoped that early removal of these shunts, as suggested by the authors of the present study, will reduce the likelihood of this occurrence.