Managing Chronic Subdural Hematoma in an 85-Year-Old: Surgical Risks and Alternatives

An 85-year-old woman with chronic subdural hematoma?

Dear Director Zhang,
I apologize for troubling you.
My mother-in-law has been suffering from dementia for a long time and is unable to express her pain.
She fell in her backyard on April 23.
The symptoms observed that day were as follows: 1.
General weakness and inability to stand independently.
2.
Prolonged periods of drowsiness (even falling asleep in seconds).
3.
No change in appetite.
4.
Frequently rubbing her head and the right temple when awake.
5.
Tenderness in the area around the right rib cage.

On the afternoon of May 1, we noticed that her condition was not good, so we took her to the hospital.
The diagnosis provided by the hospital was: 1.
Fractures of the 4th and 5th ribs on the right side.
2.
Chronic subdural hematoma (this is the main point of inquiry).
The physician recommended surgery, which would involve creating drainage holes on both sides of her head.
However, due to her advanced age, although it is not considered a major surgery, there are concerns regarding her body's ability to tolerate the procedure.
We are deeply worried about the possibility of complications such as paralysis post-surgery (she is currently on anticoagulant medication).
Additionally, since she is still able to eat orally with the help of a caregiver, we fear that surgery might lead to a rapid decline in her condition.
We are truly at a loss and would like to ask if there are any symptoms that would allow us, as family members, to observe her condition for a while longer before deciding on surgery.
After all, it has been nearly 10 days since her fall until the hospital examination, and we are hopeful that her condition remains stable and will not worsen.

Furthermore, considering the extremely high risks associated with surgery, we would prefer to avoid putting her through the ordeal of another operation and would like to support her through this difficult time in a more comfortable manner.
Are there any other treatment options that might be more suitable for her current situation? As her children, we are contemplating the possibility of maintaining her current state for a few more months, allowing us to spend more time with her while weighing the risks.
If her condition can be stabilized, we would choose not to proceed with surgery.
Conversely, if her situation is irreparable and likely to deteriorate rapidly, we would opt for surgery to seize any opportunity.
Thank you once again for taking the time to provide us with your insights!

Liao Xiansheng, 60~69 year old female. Ask Date: 2022/05/04

Dr. Zhang Junwei reply Neurosurgery

Chronic subdural hematoma has a certain probability of worsening (the likelihood varies from person to person).
Aside from surgical intervention, there are no other effective treatment options.
Observation to see if it resolves spontaneously is also possible, but the likelihood of this occurring is low.

Reply Date: 2022/05/04

More Info

Managing chronic subdural hematoma (CSDH) in elderly patients, especially those with underlying conditions such as dementia, presents a complex challenge. In your case, your mother-in-law's situation is particularly delicate due to her age (85 years), her cognitive status, and the presence of a chronic subdural hematoma following a fall.
Chronic subdural hematomas are often the result of minor head trauma, which can lead to the accumulation of blood between the brain and its outermost covering (the dura mater). In older adults, the brain tends to shrink, making the bridging veins more susceptible to tearing, which can lead to these hematomas. Symptoms can vary widely, and in some cases, they may be subtle or mistaken for other conditions, especially in patients with cognitive impairments.

Surgical Risks and Considerations
1. Surgical Risks: The primary treatment for a significant chronic subdural hematoma is surgical intervention, typically via burr hole drainage or craniotomy. However, surgery in elderly patients carries risks, including:
- Anesthesia complications: Older adults may have a higher risk of complications from anesthesia due to comorbidities.

- Postoperative cognitive decline: There is a risk of worsening cognitive function post-surgery, particularly in patients with pre-existing dementia.

- Neurological deficits: There is a potential for new neurological deficits, including paralysis, especially if there are complications during the procedure.

2. Non-Surgical Management: In some cases, especially if the hematoma is small and the patient is stable, a conservative approach may be considered. This involves:
- Observation: Regular monitoring of symptoms and repeat imaging studies (CT or MRI) to assess the size of the hematoma and any changes in the patient's condition.

- Symptomatic treatment: Managing symptoms such as pain or discomfort without immediate surgical intervention.

Monitoring and Decision-Making
Given your mother-in-law's current condition, it is crucial to monitor her closely for any signs of deterioration. Symptoms that may indicate a need for urgent surgical intervention include:
- Increased confusion or lethargy.

- New or worsening neurological deficits (e.g., weakness, difficulty speaking).

- Severe headaches that do not respond to pain management.

If her condition remains stable, and she continues to eat and interact with caregivers, it may be reasonable to delay surgery. However, it is essential to maintain open communication with her healthcare team. They can provide guidance on how often to monitor her condition and when to seek further evaluation.

Alternative Treatments
While surgery is the most definitive treatment for chronic subdural hematoma, there are no widely accepted non-surgical alternatives that can effectively resolve the hematoma. However, supportive care, including physical therapy and cognitive support, may help improve her quality of life.

Conclusion
Ultimately, the decision to proceed with surgery should be made collaboratively with her healthcare providers, weighing the risks and benefits in light of her overall health status and quality of life considerations. If you feel uncertain, seeking a second opinion from a neurosurgeon or geriatric specialist may provide additional insights. It is commendable that you are considering her comfort and quality of life in this difficult situation. Your family’s support and presence will be invaluable as you navigate this challenging time.

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