Clinical practice guidelines for the care of patients with a chronic subdural haematoma: multidisciplinary recommendations from presentation to recovery
Daniel J. Stubbs, Benjamin M. Davies, Ellie Edlmann, Akbar Ansari, Tom Bashford, Philip Braude, Diederik Bulters, Sophie Camp, Georgina Carr, Jonathan Coles, David de Monteverde-Robb, Jugdeep Dhesi, Judith Dinsmore, Nicholas R. Evans, Emily Foster, Elaine Fox, Ian Froom, Conor S. Gillespie, Natalie Gray, Kirsty Grieve, Peter Hartley, Fiona Lecky, Angelos G. Kolias, John Jeeves, Alexis Joannides, Thaı́s Minett, Iain Moppett, M. H. Nathanson, Virginia Newcombe, Joanne Outtrim, Nicola Owen, Lisa Petermann, Shvaita Ralhan, David Shipway, Rohitashwa Sinha, William C. Thomas, Peter C. Whitfield, Sally Wilson, Ardalan Zolnourian, Mary Dixon‐Woods, David K. Menon, Peter J. Hutchinson, Gideon Adegboyega, Meriem Amarouche, Nicholas Borg, Jamie Brannigan, Paul M. Brennan, Charlotte Brown, Christopher Corbett, Rúben Dammers, Tilak Das, E. Feilding, Githmi Palahepitiya Gamage, Mary P. Galea, Laurence Glancz, Edward Goacher, Felix Gooding, Robert Grange, Taj Hassan, Dana C. Holl, Julia Jones, Richard Knight, Astri M.V. Luoma, Keng Siang Lee, Orla Mantle, Adele Mazzoleni, Harry Mee, Oliver Mowforth, Stephen R. Novak, Vian Omar, George Peck, Amy Proffit, Jennifer Ramshaw, Davina Richardson, Ahmed‐Ramadan Sadek, Katie Jane Sheehan, Francoise Sheppard, Navneet Singh, Charlotte Skitterall, Christelle Smit, Martin Smith, Rhonda Sturley, Alvaro Yanez Touzet, James Uprichard, Matthew Watson, Mark Wilson, Vickie Yeardley
Abstract
INTRODUCTION: A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway. METHODS: Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care. RESULTS: We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery. CONCLUSIONS: We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.