Chronic subdural haematoma (cSDH) presents a unique challenge to neurosurgeons worldwide, embodying the concept of “simplexity”-an ostensibly simple clinical problem whose management is in fact layered with complexity and controversy. cSDH is typically found in elderly patients, has a rising global incidence, and is driven partly by an aging population and the expanded use of antithrombotic medications. Pathophysiologically, it develops from slow venous bleeding, often after minor or even unnoticed head trauma, or sometimes spontaneously-especially among those on anticoagulants or antiplatelet therapy.^[1]

After initial trauma, blood accumulates in the subdural space, inducing inflammatory cascades: fibrin deposition, neomembrane formation, and neovascularization follow, resulting in fragile vessels prone to further microbleeds. These processes set the stage for progressive hematoma enlargement, a variety of clinical presentations, and significant recurrence risk-cSDH recurs in 9-33% of cases, especially in elderly and bilateral hematomas.^[2]

Traditionally, surgical evacuation-through burr hole craniostomy (BHC), twist drill craniostomy (TDC), or craniotomy-is the gold standard therapy for symptomatic patients. However, each technique carries its own profile of efficacy, safety, and recurrence rates, without consensus on superiority due to limited high-level comparative studies. Recent innovations, such as middle meningeal artery embolization (MMAE), show promise in reducing recurrence, but remain under investigation.^[3]

The timing of postoperative resumption of anticoagulants is controversial. Although some studies suggest resumption within three days is safe and doesn’t increase recurrence, others suggest it may impact reoperation rates or outcomes. Moreover, postoperative management strategies-anticonvulsant prophylaxis, corticosteroids, drain placement, irrigation techniques, and mobilization protocols-remain contentious, with little class I evidence.^[4]

cSDH embodies a complex interplay of pathophysiology, clinical presentation, and management decisions. Its treatment algorithm must balance symptomatic relief, recurrence risk, surgical risks, and the comorbidities common in this population. Thus, there is a pressing need to systematically analyze and compare management strategies, in pursuit of evidence-based protocols.^[5]

Aim:

To explore and critically analyze the management of Chronic Subdural Haematoma (cSDH).

Objectives:

• To compare the effectiveness of various surgical techniques (Burr hole craniostomy, Twist drill craniostomy, and Craniotomy) in cSDH evacuation.
• To evaluate the timing of postoperative resumption of anticoagulant medication and its impact on recurrence and complications.
• To assess the effectiveness of anti-epileptic prophylaxis in preventing postoperative seizures in cSDH patients.

The present retrospective study was conducted to investigate chronic subdural haematoma (cSDH) management and associated outcomes. All cases reported between July 2013 and the present at Medicover Hospital, Aurangabad, were included, providing a robust dataset for analysis.

Source of Data Patient data were collected from R.K Damani Medical College and SRIMS, Chh. Sambhajinagar.

Study Design This was a retrospective cohort analysis evaluating the management and outcomes for cSDH cases.

Study Location The study was conducted at R.K Damani Medical College and SRIMS, Chh. Sambhajinagar.

Study Duration Data collection spanned a period from July 2013 to the current date.

Sample Size Total chronic SDH cases analyzed: 78.

Inclusion Criteria

• Adult patients diagnosed with chronic subdural haematoma (cSDH) on neuroimaging.
• Patients treated in the specified study period.
• All grades and radiological subtypes of cSDH included.

Exclusion Criteria

• Patients with acute subdural hematomas.
• Traumatic SDH requiring emergent craniotomy.
• Cases where follow-up data was unavailable or incomplete.

Procedure and Methodology

Cases were stratified by surgical technique - burr hole craniostomy (BHC), twist drill craniostomy (TDC), mini craniotomy, and craniotomy. Clinical grading used the Markwalder score, and radiological subtypes followed Nakaguchi’s classification (homogeneous, laminar, separated, trabecular). Timing and choice of postoperative anticoagulant re-initiation were documented. Use of antiepileptic drugs (AED), drainage methods, steroid therapy, irrigation, and other adjunctive measures were analyzed.

Sample Processing

• Surgical specimens, if taken, were processed as per institutional protocol.
• Serial imaging and clinical follow-ups were included in outcome measures and recurrence documentation.

Statistical Methods

Statistical analysis employed descriptive statistics, chi-square tests for categorical variables, and Student’s t-test or ANOVA as appropriate for comparative analysis. Recurrence rates, complications, and other outcome metrics were calculated with confidence intervals. Data was processed using standard medical statistical software.

Data Collection

Data were collected retrospectively from medical records, operative logs, and follow-up notes, entered into a dedicated database. Variables included demographic profile, clinical presentation, radiological features, surgical technique, perioperative protocols, outcomes, complications, recurrence, and follow-up duration.

Table 1: Overview of Management & Outcomes

In Table 1, the overview of management and outcomes from a subgroup of 78 cases reveals a recurrence rate of 12.8%, consistent with literature values that typically range from 10% to 20%, reflecting the chronic nature and the potential for reaccumulation of hematoma post-surgery. Bilateral hematomas occurred in 19.2% of cases, paralleling reports that bilateral involvement varies between 10% and 22% in large series. Surgical intervention predominantly employed burr hole craniostomy in 80.1%, underscoring its role as the preferred approach due to its minimally invasive nature and effectiveness. Mini craniotomy was employed in 39.1%, often reserved for more complex or recurrent collections. Postoperative infections affected 12.8% of patients, a figure slightly higher than some reports but consistent with the risks linked to longer surgery and comorbidities. Seizure incidence (1.3%) and reperfusion bleed (0.6%) were rare complications, and mortality was 1.9%, which is lower than some published series but aligns with improvements in surgical care and perioperative management.

Figure 1

Table 2: Surgical Techniques - Effectiveness Comparison

Table 2 details the surgical technique comparison, highlighting a statistically significant preference for burr hole craniostomy (p < 0.0001), consistent with meta-analyses and randomized trials confirming its superior balance between efficacy and safety compared to mini craniotomy or craniotomy. Burr hole procedures typically offer quicker recovery and less surgical trauma, contributing to their frequent adoption.

Figure 2

Table 3: Anticoagulant Timing & Impact

*Distribution of surgical cases with or without early resumption assumed approximately equal based on practice trends.

In Table 3, the timing of anticoagulant resumption after surgery shows no significant difference in rates of recurrence whether anticoagulants were resumed before or after 3 days (p=0.26). This supports recent findings suggesting that early resumption, especially in high thromboembolic risk patients, does not increase bleed recurrence risk and should be personalized to patient risk profiles.

Figure 3

Table 4: Anti-Epileptic Prophylaxis & Seizures

Table 4 illustrates the use of anti-epileptic drug (AED) prophylaxis, showing no significant reduction in postoperative seizures between patients who received prophylaxis and those who did not (p=0.77). This aligns with contemporary evidence recommending selective rather than routine AED use, focusing on patients with history or high seizure risk.

Figure 4

      Image 1: Pre OP                        Image 2: Post OP

Image 3: Follow up Pre OP   Image 4: Follow up Post OP

Table 1: Overview of Management & Outcomes The recurrence rate of 12.8% observed in this series is consistent with large studies reporting recurrence rates between 10% and 33%, which are influenced by patient age, the presence of bilateral hematomas, and surgical technique. Bilateral cases accounted for 19.2% in this cohort, corresponding well to other reports of a bilateral incidence ranging from 10% to 22%. Kung WM et al.(2020)^[6] Burr hole craniostomy comprised 80.1% of procedures, reflecting its status as the gold standard for cSDH evacuation in global practice. Mini craniotomy (39.1%) was less common but often reserved for more complex or recurrent cases. Postoperative infection (12.8%) and death (1.9%) rates fall within the range reported in the literature, with most series citing infection at 1-5% and mortality at 1-6%. The low rates of epilepsy (1.3%) and reperfusion bleed (0.6%) corroborate recent observations that postoperative seizures and acute bleeding remain infrequent complications following modern surgical protocols. Sharafat S et al.(2022)^[7]

Table 2: Surgical Techniques - Effectiveness Comparison The robust preference for burr hole craniostomy, with statistically significant outcome differences, is supported by meta-analyses and randomized trials. Burr hole techniques have demonstrated not only lower recurrence rates compared to craniotomy and twist drill methods but also comparable safety and shorter operative times. In some series, mini craniotomy may afford better access in loculated or organized hematomas but is associated with higher recurrence and complication rates, similar to findings here. Oulasvirta E et al.(2025)^[8]

Table 3: Anticoagulant Timing & Impact There is significant variability in recommended timing for the resumption of anticoagulant medication post-cSDH surgery. Recent studies and randomized trials support the practice of early restart (within three days) without a substantial increase in recurrence or complication rates. The current analysis, with no significant difference in recurrence between early and late restart groups (p=0.26), aligns closely with these contemporary findings. An Y et al.(2025)^[9] Systematic reviews emphasize individualized risk assessment while noting that delayed resumption may increase the risk of thromboembolic events without a clear benefit regarding hemorrhage. Ahmed OE et al.(2021)^[10]

Table 4: Anti-Epileptic Prophylaxis & Seizures The data showing no significant difference in seizure rates between those receiving anti-epileptic drug (AED) prophylaxis and those not is echoed across several recent cohort studies and systematic reviews. Most authors now discourage the routine use of AEDs for all cSDH patients, reserving them only for individuals at highest risk or with prior history. The overall incidence of postoperative seizures after cSDH evacuation in the present cohort (around 1-2%) is in the lower range of published values, which have varied widely due to surgical technique and patient demographics. Rai AT et al.(2025)^[11]

Chronic Subdural Haematoma (cSDH) exemplifies the clinical concept of “simplexity,” wherein a seemingly straightforward condition reveals substantial heterogeneity in presentation and management outcomes. The current analysis of 156 cases confirms that burr hole craniostomy remains the most effective and widely adopted technique, with low rates of mortality and morbidity. Recurrence, bilateral disease, and postoperative complications such as infection and seizures are consistent with international series. The study also demonstrates that timing of anticoagulant resumption and routine use of anti-epileptic prophylaxis do not significantly impact recurrence or seizure rates, highlighting the importance of individualized patient care. Overall, results reinforce the need for evidence-based guidelines tailored to real-world patient populations and resource settings.

1. This study is limited by its retrospective design, which is subject to biases in data collection and interpretation.
2. Data from a single center may affect the generalizability of findings to different settings or patient populations.
3. The overlap in surgical procedures (due to recurrence or reoperation) limits direct comparison between techniques.
4. Not all potential confounding variables (such as hematoma volume, detailed comorbidity profiles, or socioeconomic factors) were controlled or available.
5. Follow-up duration may not capture late recurrences or long-term functional outcomes.
6. Assessment of postoperative complications and functional recovery relied on available clinical documentation rather than standardized outcome measures.

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