Chronic subdural hematomas and the elderly.

Dear Editor,

We have read with interest the recent paper by Octavio de Araújo, et al.: “Chronic subdural haematomas and the elderly: Surgical results from a series of 125 cases: Old ‘horses’ are not to be shot!”,[1] and we would like to make a number of comments.

First, we are surprised that the study includes pediatric cases since it is well established that the clinical, radiological, and therapeutic characteristics of chronic subdural hematomas (CSDH) in such cases are different to those observed in adults. Most published multi-patient studies do not include pediatric cases.[24] In addition, the study title alludes to chronic subdural hematomas in the aged. So, why are juveniles included? This can distort the results. Juveniles with CSDHften present with other pathologies that foster the development of hematomas such as congenital coagulation problems, arachnoids cysts, etc. Did any of the patients in the study present with such pathologies?

Second, in relation to patient symptoms, the authors should indicate if the patients in the study had any type of cognitive problem. In our experience, and that of numerous authors, behavioral problems are present in 25-35% of patients, with a tendency to increase with age[3]

We are also surprised that all the patients were subject to surgery under general anesthesia. Our experience, and that of many clinicians, is that surgery is possible with local anesthesia in 75% of cases, with reduces the number of deaths associated with general anesthesia.[235]

Third, the authors of the study indicate that in their results: “Postoperative hydrocephalus and cerebrospinal fluid leak were not found to correlate with outcome in this study (P > 0.05).” However, nowhere do they indicate how many fistula or hydrocephalic cases they encountered.

Finally, we do not share the view that: In concern to the surgical technique, it is not clear, which is the best surgical procedure for each patient. In the literature there are numerous studies, prospective as well as retrospective, which demonstrate that one or two trepanation holes with subdural drainage is currently the treatment of choice for chronic subdural hematoma.[26]

We would like to thank the authors for their interest in our article and we found their comments both constructive and thoughtful.

It is the protocol, in our hospital, to perform surgical treatment of all cases of chronic subdural hematomas under general anesthesia, and this is supported in the literature.[123]

The surgical technique is also a point of debate and the literature also reveals that different techniques are still being used for the treatment of chronic subdural hematomas.[123]

Even though there are some points that may raise discussion in our paper, it is our belief that the article still adds important information to the literature regarding chronic subdural hematomas.