Construction and Preliminary Exploration of a Stratified Treatment System for Chronic Subdural Hematoma: A Retrospective Analysis of 347 Patients

BACKGROUND: Chronic subdural hematoma (CSDH) presents management challenges due to variable recurrence rates and the limitations of uniform treatment strategies. This study aimed to describe and preliminarily explore a volume- and structure-based stratified treatment framework for individualized CSDH care. METHODS: We retrospectively analyzed 347 patients with CSDH treated at a single center between January 2020 and December 2025. Patients were allocated according to a predefined institutional protocol into: Group A (medical management, volume <30 mL, n = 126), Group B (middle meningeal artery embolization, 30-50 mL, n = 36; 16 patients required additional burr-hole drainage), Group C (burr-hole drainage, >50 mL with simple structure, n = 167), and Group D (MMA ligation plus neuroendoscopic evacuation for complex hematomas, n = 18). Outcomes were assessed at 6 months using descriptive statistics, Kaplan-Meier analysis, and Firth penalized logistic regression. A summary dataset was used to verify baseline characteristics and recurrence outcomes. RESULTS: The 347 patients included 286 males and 61 females, with a mean age of 72 ± 11 years (range, 21-94 years). Baseline hematoma volume and midline shift differed significantly among the groups (P < 0.001). The initial treatment success rates were as follows: Group A, 71% (90/126); Group B, 56% (20/36); Group C, 91% (152/167); and Group D, 100% (18/18). In Group B, 16 patients (44%) required additional burr-hole drainage. Multivariable analysis identified complex hematoma features as a risk factor for recurrence (OR = 8.95, P < 0.001), whereas the combined procedure was associated with a lower risk of recurrence (OR = 0.02, P < 0.001). Propensity score matching (15 matched pairs) suggested a lower recurrence rate with the combined approach (0% vs. 13%); however, the difference was not statistically significant (P = 0.22, Fisher's exact test). CONCLUSION: This retrospective, single-center exploratory analysis suggests that a stratified treatment approach based on hematoma volume and structure is feasible. The combined surgical strategy (MMA ligation + endoscopy) showed promising short-term results in complex CSDH, warranting prospective validation.