Patients with cSDH presenting with new or worsening neurological deficits, especially if they are debilitating and adversely affecting quality of life require urgent medical and surgical attention. Neurological and neurosurgical critical care team need to stabilize the patient by reversing any underlying coagulopathy states in order to prevent further hematoma expansion.In the event of brain herniation and presumed ICP elevation and CPP compromise, step-wise ICP management should be instituted promptly.Seizure prophylaxis treatment is reasonable. Timing of surgical evacuation is not always easy to determine but the presence of significant neurological deficits with impending herniation require immediate surgical Intervention. Consideration of the clot density along with patient’s current neurological status would determine the timing and type of surgical interventions. Postoperative critical care management is not trivial. In addition to detecting any changes in neurological conditions, timely initiation (typically within the first 48 hours if clinical and radiographic conditions are stable with no co-existing coagulopathy) of venous thromboembolism prophylaxis is essential. Resuming antiplatelets and anticoagulants are warranted for those with clear indications including atrial fibrillation, atrial thrombus, known deep vein thrombosis, mechanical heart valves and other preexisting hypercoagulable conditions, but it is generally advised to hold antiplatelets and anticoagulants for about 10-14 post injury and/or surgical intervention.

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