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Chronic subdural haematoma
Chronic subdural haematoma is a collection of blood between the dura and the arachnoid that forms slowly, usually after a minor or forgotten injury in an older adult with brain atrophy and anticoagulants; it presents weeks after the injury with fluctuating confusion, headache, falls and one-sided weakness, and the treatment of significant symptoms is burr-hole drainage with a drain.
Why it matters in the exam
The exam presents an older adult taking an anticoagulant or aspirin, with "rapid" or fluctuating cognitive decline over several weeks, a gait disturbance or mild weakness, sometimes with no memory of an injury. Candidates are asked for the first test (head CT) and the finding — a crescent-shaped collection that crosses suture lines, of low (dark) or mixed density.
Recurring points: burr-hole drainage with a subdural drain left in place reduces recurrence (a randomised trial finding from 2009); dexamethasone did not improve and even worsened outcome (Dex-CSDH trial, 2020) and is not recommended; middle meningeal artery embolisation added to surgery reduced recurrences in trials from 2024; the haematoma recurs in about 10%–20% of cases; and anticoagulants are stopped and reversed, with an individual decision on restarting them.
Chronic subdural haematoma is one of the common neurosurgical conditions of old age, and its frequency rises with the use of anticoagulants and antiplatelet drugs. It is considered "the great mimic" because it can look like dementia, delirium, stroke or depression.
Key points
- Older adult, brain atrophy, anticoagulants, a minor or forgotten injury.
- Picture: fluctuating confusion, headache, falls, one-sided weakness.
- CT: a crescent crossing sutures, low or mixed density.
- Burr-hole drainage with a drain — for significant symptoms; no dexamethasone.
- Recurrence about 10%–20%; middle meningeal artery embolisation reduces recurrence.
Summary table
| Issue | Key point | Exam point |
|---|---|---|
| Risk factors | Age, brain atrophy, anticoagulants and antiplatelets, alcohol, falls | A minor or forgotten injury |
| Picture | Fluctuating confusion, headache, falls, one-sided weakness, drowsiness | Mimics dementia, delirium or stroke |
| CT | Crescent-shaped collection crossing sutures but not the midline; low or mixed density | Epidural haematoma — lens-shaped, does not cross sutures |
| Conservative treatment | A small collection with no or mild symptoms | Reverse anticoagulants, follow-up CT |
| Surgery | Burr-hole drainage with a drain | For significant symptoms, a thick collection or midline shift |
| What not to do | Routine dexamethasone | Worsened outcome in a trial |
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Sources
- Greenberg's Handbook of Neurosurgery, 10th edition (2023) — Chronic subdural hematoma
- Santarius et al. — Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma (randomised trial), 2009 — Recurrence and mortality
- Dex-CSDH trial — Dexamethasone in adults with chronic subdural haematoma, 2020 — Functional outcome
- Randomised trials of middle meningeal artery embolisation (EMBOLISE, MAGIC-MT), 2024 — Recurrence after surgery
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.