Implementation of a Clinical Pathway for the Treatment of Chronic Subdural Hematoma of Infancy.

Background And Objectives: There is a paucity of evidence-based recommendations to manage chronic subdural hematoma in infancy. A consensus-based clinical pathway was developed among 6 board-certified pediatric neurosurgeons under the principle of treating the children with the least invasive method possible.

Methods: Between April and June 2019, a clinical pathway was generated based on literature search and consensus building. Children with chronic or mixed-density subdural hematoma were enrolled if he/she presented with 2 or more of the following: bulging anterior fontanelle (AF), head circumference above the 95th percentile, progression of the subdural hematomas on imaging, or presence of symptoms from elevated intracranial pressure. The patients were treated based on the following stepwise pathway: AF taps, escalated to burr hole drainage with drain placement, if necessary, then subdural to peritoneal shunt insertion if both previously mentioned interventions failed. The protocol was initiated in July 2019. Each patient would have at least 6 months of follow-up, including head circumference measurements and head imaging completed after intervention.

Results: A total of 16 patients were enrolled in the clinical pathway, and 11 completed the study. Of the remaining 11 patients, 6 were successfully treated with single or repeated AF taps, 4 patients by burr hole drainage with placement of a subdural drain, and 1 patient eventually required subdural shunt insertion.

Conclusion: Use of our stepwise treatment pathway led to a decreased rate of shunt insertion compared with that reported in the literature.