Fig. 3: Showing the resolution of CSDH after adjustment of programmable VP shunt pressure.
In conclusion, this case highlights the innovative use of a programmable VPS to manage and resolve CSDH, providing a promising alternative to traditional surgical methods. As more cases are documented and studied, we may uncover more precise guidelines for utilizing this technology to its full potential in treating CSDH and other related complications.
Discussion :
The cells at the border between the arachnoid and dura mater are the source of CSDH. Cerebral atrophy stretches the abundant bridge veins in this area. A true subdural space is created when traumatized microruptures of the bridge veins cause blood to extravasate; in the absence of trauma, the subdural space is only theoretical because of the loose cellular layer in the subdural space. This layer, however, lacks the collagen that fills the third space with tight cellular connections. Since there is a smaller amount of collagen in that area, there is lower resistance to developing hematomas, encouraging their expansion. Creating the visceral and parietal neo-membranes involving the CSDH expands in response to the imbalance between injury and tissue repair processes. Vascular neoformation and enzymatic hyperfibrinolysis follow, leading to the hematoma expanding over time [5].
Surgical evacuation has been the mainstay of treatment for CSDH, especially if the hematoma is large and the patient shows significant neurological symptoms, a mass effect, or a significant midline shift. However, there have been some reports of spontaneous resolution of CSDH over the years, and some interesting theories behind their resolution have been proposed [6–8]. Small volumes, negligible mass effect, settlement in the frontal region, low density in the tomography, and insufficient midline deviation are indications that the CSDH will resolve without intervention. Clinically, people with little to no neurological symptoms or who are asymptomatic typically have spontaneous remission [9, 10]. Encouraged by these instances, clinicians have tried to discover non-surgical interventions that may improve the resolution of CSDH. These include, but are not limited to, clinical monitoring, reinforced restriction of physical activity, anticoagulant suspension, and coagulation problem repair. In addition, there have been reports of the usage of drugs such as mannitol, ACE inhibitors, atorvastatin, corticosteroids, and tranexamic acid. However, the data for the use of these drugs is limited and warrants further research [10–14].
None of these reports include a patient who develops a CSDH specifically as a complication following VPS placement. This case presents a unique scenario where a programmable ventriculoperitoneal shunt (VPS) used to treat hydrocephalus led to the development of a CSDH, which resolved spontaneously after adjusting the shunt pressure. We discovered a possible intervention that could save the patient from further morbidity by excluding the need for further surgery. It is a poetic solution in that the cause of the problem can be used to eliminate the problem itself. By carefully adjusting the pressure settings on the programmable VPS, the intracranial pressure can be modulated to facilitate the resolution of the CSDH. As the use of programmable VPS increases, we can further test this theory to ascertain its utility. This approach also reduces the need for trials of different drugs that may cause unnecessary side effects.
It is a novel solution for a chronic complication; finding an effective countermeasure for this complication will help increase confidence in physicians using VPS for treatment where required. Moreover, it opens avenues for a more personalized approach to managing CSDH, especially in patients with concurrent hydrocephalus. Given that programmable VPSs allow for non-invasive adjustments, it offers a dynamic tool for clinicians to manage intracranial pressure changes over time. Additionally, this method can lead to significant cost savings by reducing the need for repeat surgical interventions and prolonged hospital stays. Promoting the spontaneous resolution of CSDH through non-surgical means can improve patient outcomes and quality of life. Future studies should focus on the optimal pressure settings and timing for adjustments in programmable VPS to maximize their therapeutic benefits in managing CSDH.