Chronic subdural haematoma is a disease of frail older people with comorbidities, dementia among them, and its incidence is rising as populations age. Mortality is higher than in age-matched controls — which makes the long-standing framing of it as a straightforward drainage problem misleading.
This review sets out what trials since 2020 have settled and what they have not. Operative strategy has been refined. The evidence against routine corticosteroids is described as robust, which is worth stating plainly because steroids persist in practice in some places. Middle meningeal artery embolisation has been investigated as a minimally invasive adjunct, with further trials awaited. The authors' central claim is that one approach does not fit all patients, and that stratifying by risk factors for poor outcome is likely to be what determines who benefits from an adjuvant such as embolisation.
The second half of their argument is about who manages these patients. Frailty, anticoagulation, cognitive impairment and rehabilitation needs sit outside neurosurgery, and the review presses for multispecialist care as a determinant of outcome in its own right. For a neurologist or physician that is the actionable part: the medical management around the operation is not a secondary matter, and the decision about resuming anticoagulation is not someone else's to make by default.
- Do not use corticosteroids routinely — the evidence against it is described as robust
- Treat the choice of adjuvant, including middle meningeal artery embolisation, as risk-stratified rather than standard
- Assess frailty formally; it predicts outcome as much as the haematoma does
- Own the anticoagulation restart decision explicitly rather than leaving it unassigned
- Plan rehabilitation and cognitive follow-up at the time of surgery, not at discharge
Why it matters
It reframes chronic subdural haematoma from a drainage procedure into a condition whose outcome is decided largely outside the operating theatre.
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