Patients with cortical atrophy are prone to develop chronic subdural haematomas.
These can present with stroke-like (hemiplegic) syndromes or more subtly with change in affect, drowsiness or fits. Management is straightforward when there is clearly dangerous neurological harm – reduced consciousness or focal signs – but less clear in the fully alert patient without major deficit, where space re-allocation after drainage may lead to no improvement or new bleeding, and, in the elderly mortality may be relatively high. One of several cohort studies found that mortality in patients over 90 years of age was 9% versus 1% in those who were younger than 90 (and also found that GCS predicted mortality – 6% if <8 and 2% if >8.)1
Corticosteroids and/or statins (instead of drainage) have been mooted to be helpful in this condition, assuming a fully alert patient with midline shift of less than 1 cm and relatively high surgical risk (e.g. multiple comorbidities), but benefit is unclear2
The bottom line at present is aim to have surgical drainage for deteriorating neurological signs, or for fixed disabling signs or reduced consciousness; in a fully alert patient with minimal deficit, surgery is of less clear benefit, and watchful waiting may be appropriate
Christopher E, Poon MTC, Glancz LJ, Hutchinson PJ, Kolias AG, Brennan PM; British Neurosurgical Trainee Research Collaborative (BNTRC). Outcomes following surgery in subgroups of comatose and very elderly patients with chronic subdural hematoma. Neurosurg Rev. 2019 Jun;42(2):427-431. doi: 10.1007/s10143-018-0979-4. Epub 2018 Apr 21. PMID: 29679178; PMCID: PMC6502770. ↩
Scerrati A, Visani J, Ricciardi L, Dones F, Rustemi O, Cavallo MA, De Bonis P. To drill or not to drill, that is the question: nonsurgical treatment of chronic subdural hematoma in the elderly. A systematic review. Neurosurg Focus. 2020 Oct;49(4):E7. doi: 10.3171/2020.7.FOCUS20237. PMID: 33002869. ↩