Management of Chronic Subdural Hematoma

Chronic subdural haematoma represents a slowly evolving collection of blood and serous fluid between the dura mater and the arachnoid. It predominantly affects older adults and arises often after minor trauma, though spontaneous cases are increasingly recognised. The condition is driven by a fragile neomembrane, local inflammation and impaired clot stability, leading to recurrent bleeding and expansion. Clinically, patients may present with headache, cognitive decline or focal neurological deficits. The cornerstone of management remains surgical evacuation, most commonly via burr-hole drainage with insertion of a closed-system drain. This approach achieves immediate decompression but carries recurrence rates of up to 20 per cent, necessitating repeat intervention in some cases. Craniotomy is reserved for complex or organised haematomas. Conservative management, including observation and periodic imaging, may be appropriate for small, asymptomatic collections. Advances in understanding the underlying pathophysiology have prompted exploration of adjuvant therapies: arterial embolisation of the middle meningeal artery aims to starve the neomembrane vascular supply, while antifibrinolytic agents such as tranexamic acid seek to stabilise clot formation. Radiological factors—including density patterns and residual cavity volume—are increasingly used to stratify recurrence risk and guide follow-up intervals. As the global population ages, optimisation of treatment algorithms and incorporation of minimally invasive techniques are urgent priorities to reduce morbidity, recurrence and healthcare costs.

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Management of Chronic Subdural Hematoma publication trend

The graph below shows the total number of articles in management of chronic subdural hematoma across all publications each year (not limited to Nature Index journals).

Technical terms

Burr-hole evacuation: A minimally invasive surgical technique involving one or more small cranial perforations to drain subdural fluid collections.

Craniotomy: A more extensive surgical procedure in which a bone flap is removed to access and remove organised or loculated haematomas.

Middle meningeal artery embolisation: A neurointerventional procedure that occludes the arterial supply to the haematoma membrane to prevent rebleeding.

Tranexamic acid: An antifibrinolytic agent that inhibits clot breakdown and may promote stable resolution of subdural collections.

Radiological prognostic factor: An imaging characteristic, such as density pattern or cavity volume, used to predict the likelihood of haematoma recurrence.

References

1. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. Journal of Neuroinflammation (2017).
2. Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surgical Neurology International (2013).
3. Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients. Acta Neurochirurgica (2012).
4. Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology (2020).
5. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Frontiers in Neurology (2020).
6. Chronic Subdural Haematoma in the Elderly: Is It Time for a New Paradigm in Management?. Current Geriatrics Reports (2016).
7. Tranexamic Acid in Chronic Subdural Hematomas (TRACS): study protocol for a randomized controlled trial. Trials (2016).
8. Burr Hole Washout versus Craniotomy for Chronic Subdural Hematoma: Patient Outcome and Cost Analysis. PLOS ONE (2015).