Feature Article

Chronic subdural haemorrhage. Untangling the complexities

Nicholas Little, Heath French



Chronic subdural haemorrhage (CSDH) is a common presentation in both the emergency department and in general practice. It is primarily a disease of the elderly that, if symptomatic, requires surgical evacuation. It is common for these patients to take anticoagulation or antiplatelet medication, which commonly delays surgery. Given the frequent multiple comorbidities, management requires careful discussion with the patient and family.

Key Points

  • Chronic subdural haemorrhage (CSDH) is a separate entity to acute subdural haemorrhage with different pathophysiology and management.
  • Risk factors for CSDH are old age, recurrent falls, anticoagulation or antiplatelet medication and alcohol use.
  • Just under half of the patients presenting with CSDH will be on anticoagulation or antiplatelet medication.
  • Percutaneous twist drill, burr hole and minicraniotomy have been shown to have similar efficacy in the evacuation of CSDH.
  • When deciding when to restart anticoagulation or antiplatelet medication in postoperative patients with a thromboembolic risk, the risk of recurrent haemorrhage must be weighed against the risk of a thromboembolic event while the medication is being withheld.
  • Careful discussion with the patient and their family regarding the risks, benefits and expectations of surgery is key in the management of CSDH.
  • Often CSDH can be managed conservatively as many collections will resolve without any specific intervention. In general, intervention is determined on clinical grounds.
  • Medical therapy, such as corticosteroids, is not usually used to treat this condition.
  • Recurrence/persistence of subdural collection is relatively common (more than 15% of cases), and most patients with CSDH need to be followed to resolution with imaging.

    Picture credit: © GCA/SPL