[Diagnostic and therapeutic management of chronic subdural hematoma in elderly patients]

Chronic subdural hematoma (CSDH) is a common neurosurgical condition in the elderly population, with an increasing incidence attributed to longer life expectancy, widespread use of anticoagulant or antiplatelet agents, and a higher risk of falls. Its diagnosis remains challenging due to its nonspecific and often subtle clinical presentation, typically including confusion, cognitive decline, gait disturbances, or somnolence, which may mimic other geriatric syndromes. Neuroimaging is essential, with non-contrast CT as the first-line modality, complemented by MRI in selected cases to better characterize complex or atypical lesions. Surgical evacuation via burr-hole trepanation remains the cornerstone of management in symptomatic patients, particularly when associated with significant mass effect. The addition of subdural drainage and intraoperative irrigation with warm saline (37 °C) has been shown to reduce postoperative recurrence. Recently, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive technique aimed at occluding the vascular supply of the neomembrane responsible for persistent microbleeding. Recent randomized controlled trials have demonstrated the efficacy and safety of MMA embolization in reducing recurrence rates, either as a primary or adjunctive therapy, particularly in high-risk or inoperable patients. Beyond the procedure itself, patient outcomes largely depend on a multidisciplinary approach encompassing neurosurgery, interventional neuroradiology, anesthesiology, geriatrics, and rehabilitation. Optimal perioperative management includes correction of coagulation disorders, monitoring of fluid balance, and individualized postoperative surveillance. The integration of novel endovascular strategies with traditional surgical treatment opens new avenues for personalized care and improved prognosis in this vulnerable population. Further research is warranted to refine patient selection criteria for embolization, evaluate long-term outcomes, and determine its place in treatment algorithms.