Bilateral chronic subdural haematoma

The proposition that chronic subdural haematoma (CSH) is largely amenable to surgical treatment¹ can only be substantiated, in the short term, by a national audit of neurosurgical practice, and, in the long term, by a randomized controlled trial. The latter strategy was the one suggested by a leading neurosurgical authority who noted that there were no randomized controlled trials to yield class I evidence supporting any of the treatment options for chronic subdural haematoma; and that the available class II evidence relied on only six trials.²

What is even more worrying is the reliance, at least in one instance, on case control studies such as the one dating back to 1992,³ which was subsequently cited as recently as 1999 to support a proposed management option for CSH.⁴ In essence, that option was based on the premise that ‘... there is little point in active treatment over the age of 65 for those who remain in coma (Glasgow Come Scale 8 or less) for more than 6 hours...’.⁴ Such statements, I maintain, should, at least, be qualified by the acknowledgement that, given the biological diversity of the over 65s, clinical outcomes in that age group might be better predicted by the biological age/physiological reserve index than by chronological age.⁵