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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
Competing interests None declared.