Current Clinical Standards for the Treatment of Chronic Subdural Hematoma in Austrian, German, and Swiss Neurosurgical Units

Aims: Despite the treatment of chronic subdural hematomas (SDH) is one surgical procedure that neurosurgeons perform earliest in their training, the technical steps and strategy of treatment vary between centers. Although an abundance of literature about the treatment of chronic SDH is available, there is little evidence clarifying which treatment is most successful. The aim of this study was to examine and compare the current clinical standards.

Methods: Heads of department of all neurosurgical units in Austria, Germany, and Switzerland, as listed on the national neurosurgical societies’ Web sites, were invited to participate with a personal token to access a web-based survey. A total of 159 invitations and up to 9 reminder e-mails were sent.

Results: Eighty-four invitees (53%) completed the survey. The most standard surgical strategy was a single burr hole in 52 (65%) of the responding neurosurgical units; double burr holes were performed as primary procedure in 16 centers (20%), a small osteoplastic craniotomy in 4 (5%), and twist drill craniostomy in 8 (10%). Although 100% of Austrian respondents and 72% of German respondents preferred single burr hole, the double burr hole (p < 0.01*) was preferred in Switzerland 91%. Seventy-two (90%) would place a drain in estimated 75 to 100% of cases or whenever possible/safe. Sixty-five use subdural-external drains and seven use subgaleal-external drains. In Switzerland, almost 50% preferred subgaleal drains, while in Austria and Germany almost 100% preferred subdural drains (p < 0.01*). Thirty-six (49%) agreed with the statement that watchful waiting was an option for the treatment of chronic SDHs, except 19 (23.4%) that disagreed. Eighteen (23%) would consider corticosteroids and 34 (45%) tranexamic acid as part of their armamentarium for the treatment of SDHs.

Conclusions: The results of this survey reflect the current evidence available in literature. The benefits of using of a drain seem generally accepted, although there was no agreement regarding the type of drain and surgical approach to the hematoma as well as the presence of some international differences.