Background <p>Limited research has addressed how to optimally balance the risk of bleeding and thrombosis while selecting the most effective treatment strategy for chronic subdural hematoma (CSDH) in elderly patients undergoing anticoagulant (AC) or antiplatelet (AP) therapy at the time of diagnosis.</p> Methods <p>We searched for studies published between January 2017 and January 2025 in PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane systematic review registries involving older adults diagnosed with CSDH who are receiving AC or AP therapy.</p> Results <p>Ten studies comprising a total of 3,962 patients were included in the final analysis, with mean ages ranging from 72 to 84.4 years. Preoperative antithrombotic (AT) therapy was not significantly associated with postoperative recurrence of CSDH; however, the use of multiple AT agents may increase the risk of recurrence and the need for reoperation. Current evidence does not support a correlation between the duration of preoperative drug withdrawal and postoperative recurrence. Four studies reported that the majority of patients resumed AT therapy within two weeks postoperatively, although the optimal timing for the resumption of AP and AC therapy remains uncertain. Prolonged discontinuation or delayed resumption of AT therapy appears to increase the risk of thromboembolic events, whereas early resumption may mitigate this risk without significantly increasing the recurrence rate.</p> Conclusion <p>Antithrombotic therapy did not significantly increase the risk of postoperative recurrence or reoperation in older patients with CSDH, and the duration of preoperative drug withdrawal was not associated with clinical outcomes. In the absence of clear contraindications or high-risk factors, AT therapy should be resumed as early as possible, as prolonged discontinuation may elevate the risk of thromboembolic events. Further studies are warranted to determine the optimal timing for the postoperative resumption of AC and AP therapy respectively.</p>