Chronic Subdural Hematoma - Surgical Management (SVIN 2025)

Algorithm Steps

1. ▶

   Start

   Chronic Subdural Hematoma (cSDH) Identified

   CT showing chronic (hypodense/isodense) extra-axial collection

   1. ◆

      Decision

      Symptomatic?

      Assess for symptoms requiring intervention

      • Headache
      • Cognitive decline/confusion
      • Gait disturbance
      • Focal weakness
      • Speech difficulty
      • Seizures
      1. ●

         Action

         Symptomatic - Evaluate for Surgery

         Most symptomatic patients benefit from surgery

         1. ◆

            Decision

            On Anticoagulation/Antiplatelets?

            Common in elderly cSDH population

            1. ●

               Action

               Anticoagulation Management

               Hold/reverse prior to surgery

               • Hold warfarin, give Vitamin K ± PCC
               • Hold DOACs (half-life dependent)
               • Hold aspirin: controversial, often continued
               • Dual antiplatelet: hold P2Y12 if possible
               • Platelet transfusion rarely needed
               1. ◆

                  Decision

                  Surgical Approach

                  Select based on hematoma characteristics

                  1. ●

                     Action

                     Burr Hole Drainage

                     Most common approach (SVIN 2025 consensus)

                     • 1-2 burr holes over collection
                     • Irrigate until clear
                     • Place subdural drain (24-48h)
                     • Drain reduces recurrence
                     • Similar outcomes to craniotomy
                     1. ◆

                        Decision

                        Consider MMA Embolization?

                        Middle meningeal artery embolization per SVIN 2025 Consensus

                        • EMBOLISE: 4.1% vs 11.3% recurrence (p=0.008)
                        • STEM: 16% vs 36% recurrence (OR 0.36)
                        • MAGIC-MT: 6.7% vs 9.9% recurrence
                        • Can be done with or after surgery
                        • Especially for high recurrence risk
                        1. ●

                           Action

                           MMA Embolization (SVIN 2025)

                           Reduces recurrence by ~50% per RCT data (Class I evidence)

                           • Onyx, Squid, or n-BCA embolic agents
                           • Can be done at time of surgery or after
                           • Fewer serious adverse events vs surgery alone
                           • SVIN: 'may become standard of care'
                           • EMPROTECT 2025: confirms benefit in high-risk
                           1. ●

                              Action

                              Post-Operative Care

                              Standard post-craniotomy management

                              • Subdural drain for 24-48h
                              • Flat positioning (controversial)
                              • Hydration to promote brain re-expansion
                              • Repeat CT before discharge
                              • Seizure prophylaxis (institution-dependent)
                              1. ◆

                                 Decision

                                 Recurrence?

                                 Recurrence rate 5-30%

                                 1. ●

                                    Action

                                    Recurrence Management

                                    Options for recurrent cSDH

                                    • Repeat burr hole drainage
                                    • MMA embolization (if not done)
                                    • Craniotomy with membrane removal
                                    • Address underlying factors (anticoag, atrophy)
                                 2. ✓

                                    Outcome

                                    Resolution

                                    Follow-up imaging to confirm resolution; resume anticoagulation per indication

                  2. ●

                     Action

                     Craniotomy

                     Consider for organized/septated hematoma

                     • Better for loculated collections
                     • Allows membrane removal
                     • Higher morbidity than burr hole
                     • Reserved for complex cases
                  3. ●

                     Action

                     Twist Drill Craniostomy

                     Bedside option for poor surgical candidates

                     • Can be done at bedside
                     • Lower anesthesia risk
                     • Higher recurrence rate
                     • For patients unfit for OR
      2. ●

         Action

         Asymptomatic/Minimal Symptoms

         Consider observation for small, asymptomatic cSDH

         • Serial imaging q2-4 weeks
         • Monitor for symptom development
         • Many resolve spontaneously
         • Address anticoagulation if applicable