Chronic Subdural Hematoma in the Super-Aged Society: From a Traumatic Curiosity to a Self-Perpetuating Vascular-Inflammatory Disease

The review proposes that the disease concept of cSDH has shifted from a static post-traumatic blood pool to a chronic, self-perpetuating process driven by inflammation, pathological angiogenesis, and hyperfibrinolysis within an outer neomembrane. Relative to the traditional view of cSDH as a simple mechanical consequence of trauma, this repositioning places it within a vascular-inflammatory disease framework. Based on a synthesis of recent ultrastructural, histopathological, and clinical evidence, representing review-level integration.

The review systematically organizes patient- and hematoma-related risk factors for cSDH and outlines conventional conservative and surgical treatment. It presents risk factors and existing treatment pathways within a single framework, providing the comparative background for mechanism-targeted therapy. An inductive summary of existing literature; the text does not provide specific sample sizes or effect sizes.

The review focuses on contemporary evidence for middle meningeal artery embolization (MMAE) as a mechanism-targeted adjunct or alternative to surgery, covering pooled and individual randomized trial data together with recently completed and ongoing studies. It elevates MMAE from a technical description to a mechanism-targeted strategy supported by randomized trial evidence, while also discussing recurrence burden, cost-effectiveness, and reimbursement issues in Korean practice. Evidence comes from pooled and individual randomized trial data and completed and ongoing studies; the text does not report specific effect sizes.

The review concludes that current evidence supports MMAE as a promising, mechanism-targeted adjunctive strategy in selected high-risk patients rather than a universal replacement for surgery, and highlights the need for standardized technique, longer-term outcome data, and precision-medicine approaches. It gives an explicit positioning of MMAE's scope of use rather than treating it as a universal substitute. The conclusion rests on randomized trial data and ongoing studies, representing a review-level synthesis.

This review is aimed at clinicians, neurointerventionalists, and public health researchers concerned with cSDH, in the context of rising cSDH burden in super-aged societies. Its conclusions position MMAE as a mechanism-targeted adjunctive strategy in selected high-risk patients rather than a universal replacement for surgery; the reimbursement and cost-effectiveness discussion uses Korean practice as an example, and applicability elsewhere depends on local payment and referral systems. The review also indicates that standardized technique, longer-term outcome data, and precision-medicine approaches remain conditions for the field to move forward.

Readers would still watch: the magnitude of benefit and long-term outcomes of MMAE across patient subgroups, what elements a standardized technique should include, whether biomarker-based and artificial-intelligence-guided stratification can genuinely improve selection, and the clinical positioning of early transvascular access to the subdural space through the MMA. In addition, the text available here is at the abstract level and lacks figures and specific data, so the ability to summarize effect sizes, sample sizes, and trial details is limited; these are open questions to be checked against the original article.