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

Chronic subdural hematoma (cSDH) was traditionally regarded as a simple mechanical consequence of head trauma, treated by burr-hole drainage alone. Recent ultrastructural, histopathological, and clinical evidence has reframed cSDH as a chronic, self-perpetuating disease driven by inflammation, pathological angiogenesis, and hyperfibrinolysis within an outer neomembrane, rather than a static pool of blood. As Korea and other nations enter super-aged societies, the incidence of cSDH is rising steeply with age, and its associated disability and mortality are increasingly recognized as important public health concerns. This review summarizes the evolving disease concept of cSDH and its patient- and hematoma-related risk factors, then outlines conventional conservative and surgical treatment before focusing on contemporary evidence for middle meningeal artery embolization (MMAE) as a mechanism-targeted adjunct or alternative to surgery. Pooled and individual randomized trial data, together with recently completed and ongoing studies, are reviewed alongside the burden of recurrence, cost-effectiveness, and country-specific reimbursement issues exemplified by Korean practice. Emerging biomarker-based and artificial-intelligence-guided approaches to patient stratification, together with early transvascular access to the subdural space through the MMA, are also discussed. Taken together, current evidence supports MMAE as a promising, mechanism-targeted adjunctive strategy in selected highrisk patients rather than a universal replacement for surgery, and highlights the need for standardized technique, longer-term outcome data, and precision-medicine approaches as cSDH becomes an increasingly important neurointerventional and public health concern.