Surgical versus conservative management of traumatic acute subdural haematoma in older adults: a systematic review and qualitative synthesis in the RESCUE-ASDH era
Serhat Hizal, Kenan Simsek, Mustafa Tufan Pehlivan
article (Uluslararası, Hakemli) | Yazar(lar): Serhat Hizal, Kenan Simsek, Mustafa Tufan Pehlivan | Yıl: 2026 | Dergi/Kurum: EGYPTIAN JOURNAL OF NEUROLOGY PSYCHIATRY AND NEUROSURGERY | İndeks: WOS.ESCI | DOI: 10.1186/s41983-026-01230-0 | Anahtar Kelimeler: Acute subdural haematoma, Older adults, Traumatic brain injury,
Background Evidence guiding surgery versus conservative care for traumatic acute subdural haematoma (ASDH) in older adults is heterogeneous and vulnerable to treatment-selection bias. We systematically reviewed contemporary elderly-focused evidence and interpreted major all-age comparative studies as indirect evidence.Methods PRISMA 2020 was followed. PubMed/MEDLINE was searched from 1 January 2020 to 27 August 2026 for traumatic ASDH studies reporting mortality, functional outcome, treatment escalation or complications in populations aged >= 60 years, separable elderly subgroups, or explicitly elderly cohorts. Two reviewers were designated to screen, extract data and assess risk of bias. ROBINS-I/JBI tools and GRADE principles informed appraisal. Because of clinical heterogeneity, overlapping cohorts and confounding by indication, synthesis was qualitative and no pooled effect estimate was calculated.Results The search identified 126 records; 49 full-text reports were assessed and 21 reports describing 19 distinct elderly-focused cohorts were included. No completed randomised trial specifically compared surgery with conservative care in older adults. Comparative cohorts produced inconsistent mortality findings and no reproducible functional-outcome advantage for routine surgery; the certainty of this evidence was very low. Craniotomy-versus-craniectomy observations in elderly subgroups were strongly confounded by severity, while the all-age RESCUE-ASDH trial found similar functional outcomes between procedures. Limited craniotomy, endoscopic evacuation and delayed burr-hole strategies were feasible only in highly selected, neurologically stable patients. Admission GCS, pupillary response and midline shift were consistent prognostic variables; frailty was promising but insufficiently validated as a treatment-effect modifier.Conclusions Current evidence does not support a general claim that surgery improves survival or functional recovery across all older adults with traumatic ASDH. Surgery remains standard for unequivocal neurological deterioration or mass effect, but when genuine clinical equipoise exists, monitored initial conservative care may be reasonable. If evacuation is required and the bone flap can safely be replaced, craniotomy is a reasonable default; decompressive craniectomy should be guided by intraoperative swelling rather than age alone. These conclusions are limited by very low-certainty observational evidence.