Effectiveness of invasive interventions for chronic subdural hematoma: a systematic review

Chronic subdural hematoma (CSDH) is a frequent neurological problem, especially in older adults. It often presents headache as a primary symptom. The optimal approach to managing CSDH through invasive treatments is still debated, with various procedures available. We conducted a systematic review of randomized clinical trials, based on the most recent available literature, to assess the efficacy and safety of invasive interventions for the treatment of CSDH. A comprehensive search of major databases was performed according to PRISMA guidelines with an extensive consultation with experts that independently conducted study selection, data extraction, and bias assessment. The GRADE approach and RoB 2 tool were used to assess evidence quality and risk of bias. It was identified 4 studies (N.=579) meeting the inclusion criteria. Invasive interventions included burr hole craniostomy, twist drill craniostomy, and subdural drainage systems. Findings varied across studies. A Chinese study suggested shorter hospital stays with twist drill craniostomy compared to simple burr hole craniostomy. A Denmark study showed that the 48-hour drainage has a significantly higher volume of postoperative drain production compared to the 24-hour group. An Iranian study suggested fewer hematomas with burr hole irrigation without drainage compared to with drainage. Evidence on invasive interventions for CSDH is limited. Treatment decisions should be individualized based on patient factors and potential risks/benefits. Large-scale randomized controlled trials are needed to provide clearer guidelines for CSDH treatment.