From the Guidelines
Subdural hematomas are primarily caused by head trauma, especially in elderly patients or those on anticoagulants, and management depends on the hematoma size, symptoms, and progression. The causes of subdural hematoma include head trauma, falls, motor vehicle accidents, and assault, with spontaneous subdural hematomas occurring in patients with coagulopathies, alcohol abuse, or cerebral atrophy 1. Some key points to consider in the management of subdural hematomas include:
- Reversing anticoagulation if applicable, using protamine for heparin, vitamin K and prothrombin complex concentrate for warfarin, or specific reversal agents for DOACs
- Maintaining normal blood pressure and preventing secondary brain injury
- Surgical evacuation for hematomas causing significant mass effect, neurological deficits, or clinical deterioration, with primary surgical options including burr hole drainage for liquefied chronic subdural hematomas or craniotomy for acute hematomas with solid clots
- Postoperative monitoring for recurrence, seizures, and complications, with anticonvulsants like levetiracetam (500-1000mg twice daily) prescribed prophylactically in high-risk patients
- Long-term management addressing underlying risk factors, gradual return to activities, and rehabilitation for patients with residual deficits, with prognosis varying based on hematoma severity, patient age, comorbidities, and time to treatment 1. The most recent and highest quality study, published in 2023, suggests that patients on anticoagulants or antiplatelet therapy with a normal initial head CT after blunt trauma and who are neurologically intact can be safely discharged, with clear discharge instructions and return precautions warranted due to the potential for delayed intracranial hemorrhage 1.
From the Research
Causes of Subdural Hematoma
- Trauma 2, 3, 4, 5
- Anticoagulant/antiaggregant use 2, 3, 5
- Arterial rupture 2
- Oncologic hemorrhages 2
- Intracranial hypotension 2
- Idiopathic hemorrhages 2
- Active cerebrospinal fluid diversion 3
Management of Subdural Hematoma
- Decompression of neural tissue and restoration of perfusion 2
- Monitoring alone for asymptomatic patients with chronic subdural hematoma 4
- Surgical treatment for symptomatic patients, including burr hole evacuation of the hematoma in local anesthesia 4
- Reoperation using either the same burr hole or a new one for recurrent chronic subdural hematoma 4
- Craniotomy for patients with multilobulated hematomas that recur after burr hole 4
- Anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring 3
- Direct surgical management options, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems 3
Factors Affecting Outcomes
- Preoperative clinical status, antithrombotic use, surgical factors, clinical outcome, hospital length of stay, discharge destination, and complications 6
- Age, preadmission independence, preoperative Glasgow Coma Scale motor score, number of regular medications, and American Society of Anesthesiologists grades 6
- Use of a subdural drain associated with increased odds of favorable outcome and being discharged home 6