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.