# Chronic subdural hematoma with mild to moderate symptoms: The effect of initial treatment approach on clinical outcome

## TL;DR

This study finds that conservative treatment for chronic subdural hematomas with mild to moderate symptoms leads to fewer complications and shorter hospital stays compared to surgery.

## Contribution

The study provides evidence supporting a conservative-first approach for mild-to-moderate chronic subdural hematoma patients.

## Key findings

- Conservative treatment is associated with fewer complications compared to initial surgery.
- Initial surgery is linked to longer hospital stays.
- A conservative-first approach is supported for mild-to-moderate chronic subdural hematoma patients.

## Abstract

The effect of a conservative (wait-and-watch) approach in chronic subdural hematoma (cSDH) patients with mild to moderate symptoms, is poorly studied. Surgical evacuation is effective, but inherently carries the risk of surgical or anesthetic complications.

To assess the effect of conservative or operative (burrhole craniostomy) treatment on clinical outcome, in cSDH patients with mild to moderate symptoms.

This single center, retrospective cohort study included 444 cSDH patients with a Markwalder Grading Scale score 1 or 2, treated between 2012 and 2022. The primary outcomes were complication rate, length of hospital stay and 30-days’ mortality. The results were analyzed using both intention-to-treat and as-treated approaches. Propensity score techniques were applied to adjust for clinical and radiological baseline differences.

Of the 114 conservatively treated patients, 49 (43%) crossed-over to surgery. The 330 remaining patients were treated surgically. In the intention-to-treat and as-treated analysis, initial surgery was associated with a higher complication rate (OR 2.02, 95% CI 1.04–3.94; OR 2.87, 95% CI 1.04–7.91) and longer hospital stay (β 2.34, 95% CI 0.15–4.52; β 6.62, 95% CI 3.60–9.64). Conservative treatment was associated with higher 30-day mortality (as-treated OR 0.19, 95% CI 0.06–0.66, favoring surgery), but this was unrelated to cSDH.

In this selected cohort of cSDH patients with mild to moderate symptoms, a conservative approach was associated with less complications and hospital stay. For these patients, a ‘conservative treatment first’ regimen may therefore be considered. Corroboration in a prospective cohort with neurological and functional outcomes is warranted.

•Conservative treatment is associated with less complications vs. initial surgery.•Initial surgical treatment was associated with longer hospital stay.•Findings support a "conservative-first" approach for mild-to-moderate cSDH patients.

Conservative treatment is associated with less complications vs. initial surgery.

Initial surgical treatment was associated with longer hospital stay.

Findings support a "conservative-first" approach for mild-to-moderate cSDH patients.