Improving care in elderly neurosurgery initiative guideline on management of chronic subdural haematoma in older people-relevance for the geriatrician.

Chronic subdural haematoma (cSDH) is a common subtype of traumatic brain injury, typically affecting older people living with frailty and multimorbidity. Until now, no published guideline has existed internationally to guide management, perhaps explaining why the care of the older cSDH patient varies between neurosurgical centres. The Improving Care in Elderly Neurosurgery Initiative guideline is the first guideline dedicated to the care of patients with cSDH across the entire patient pathway, from initial presentation through to rehabilitation and discharge after surgery. It includes specific recommendations for those patients not requiring surgery who, in the UK, are mostly managed in satellite hospitals away from the tertiary neurosurgical centre. It therefore has relevance to clinicians across the entire UK and also potentially to a broader international audience. In this guideline commentary we summarise the key points for geriatricians and those allied specialties such as acute medicine who deliver care to a large proportion of patients with cSDH. We discuss issues and limitations relating to guideline development, in particular in the rapidly evolving field of Middle Meningeal Artery Embolisation. We also comment on factors which may influence guideline implementation and future service development. Finally we call for some form of national registry in older people sustaining SDH, which may need to be supported by financial incentives to drive investment in services for this historically neglected patient group.