{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T12:49:15Z","timestamp":1792673355263,"version":"4.5.0"},"reference-count":91,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T00:00:00Z","timestamp":1781049600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Brain Sciences"],"abstract":"<jats:p>Chronic subdural hematoma (CSDH) is traditionally described as a post-traumatic blood collection within the subdural space; however, both its anatomical localization and pathophysiology have been increasingly questioned. Ultrastructural and histopathological evidence demonstrates that no true subdural space exists under physiological conditions and that CSDH originates instead within the dural border cell (DBC) layer, a mechanically fragile and biologically active meningeal interface. Accordingly, chronic \u201csubdural\u201d hematoma may be more accurately interpreted as an intradural border cell lesion. Beyond anatomy, CSDH is a dynamic, self-sustaining disease driven by chronic inflammation, pathological angiogenesis, vascular immaturity, and localized hemostatic dysregulation. Hypoxia-induced HIF-1\u03b1\/VEGF activation promotes fragile, hyperpermeable neovessels, while local hyperfibrinolysis and kallikrein\u2013kinin activation prevent stable clot formation, driving recurrent microbleeding and plasma exudation. Consequently, hematoma persistence and recurrence represent a biological failure rather than a purely technical surgical shortcoming. This conceptual shift provides a coherent rationale for dural-targeted therapies, including middle meningeal artery embolization and pharmacological modulation of angiogenesis and fibrinolysis. Reframing CSDH as a chronic intradural and biologically active disorder has important implications for terminology, classification, and the development of mechanism-oriented, multidisciplinary management strategies.<\/jats:p>","DOI":"10.3390\/brainsci16060623","type":"journal-article","created":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T02:59:31Z","timestamp":1781146771000},"page":"623","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Chronic Subdural Hematoma Is Not Subdural: Anatomical, Biological, and Therapeutic Implications of a Misleading Definition"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8172-6134","authenticated-orcid":false,"given":"Matteo","family":"De Simone","sequence":"first","affiliation":[{"name":"Department of Medicine, Surgery and Dentistry \u201cScuola Medica Salernitana\u201d, University of Salerno, Via S. Allende, 84081 Baronissi, Italy"},{"name":"Neurosurgery Unit, University Hospital \u201cSan Giovanni di Dio e Ruggi D\u2019Aragona\u201d, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8035-4583","authenticated-orcid":false,"given":"Elena","family":"Ciaglia","sequence":"additional","affiliation":[{"name":"Department of Medicine, Surgery and Dentistry \u201cScuola Medica Salernitana\u201d, University of Salerno, Via S. Allende, 84081 Baronissi, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5491-3719","authenticated-orcid":false,"given":"Alessandro","family":"Santurro","sequence":"additional","affiliation":[{"name":"Department of Medicine, Surgery and Dentistry \u201cScuola Medica Salernitana\u201d, University of Salerno, Via S. Allende, 84081 Baronissi, Italy"},{"name":"Legal Medicine Unit, University Hospital \u201cSan Giovanni di Dio e Ruggi D\u2019Aragona\u201d, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4467-8860","authenticated-orcid":false,"given":"Anis","family":"Choucha","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Aix Marseille University, APHM, UH Timone, 13005 Marseille, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benedetta","family":"Messuti","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Surgery TD, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy"},{"name":"Department of Biology and Chemistry \u201cA. 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Allende, 84081 Baronissi, Italy"},{"name":"Unit of Interventional Neuroradiology, University Hospital \u201cSan Giovanni di Dio e Ruggi D\u2019Aragona\u201d, 84131 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4342-962X","authenticated-orcid":false,"given":"Germano","family":"Guerra","sequence":"additional","affiliation":[{"name":"Department of Medicine and Health Sciences \u201cVincenzo Tiberio\u201d, University of Molise, Via F. De Santis, 86100 Campobasso, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3905-6154","authenticated-orcid":false,"given":"Antonio","family":"De Luca","sequence":"additional","affiliation":[{"name":"Department of Mental Health and Preventive Medicine, Section of Human Anatomy, University of Campania \u201cL. 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