From the Guidelines
The patient with a suspected acute subdural hematoma requires immediate neurosurgical consultation and close monitoring, with a management plan prioritizing airway protection, oxygenation, and hemodynamic stabilization, as well as consideration for urgent non-contrast CT scan of the head for diagnosis and potential surgical intervention. Given the patient's condition, with a maximum thickness of 3 mm without mass effect, no parenchymal bleed, no midline shift, herniation, or ventricular trapping, the initial steps should focus on stabilization and further evaluation. According to the American College of Radiology Appropriateness Criteria for head trauma 1, noncontrast head CT is usually appropriate for the initial imaging of patients with acute head trauma that is mild, moderate, or severe, which aligns with the need for an urgent non-contrast CT scan in this patient. Key considerations in the management plan include:
- Airway protection and maintaining adequate oxygenation
- Hemodynamic stabilization with a target systolic blood pressure to ensure adequate cerebral perfusion without exacerbating bleeding
- Urgent non-contrast CT scan of the head for diagnosis
- Potential measures for increased intracranial pressure, such as elevating the head of bed, administering mannitol or hypertonic saline, and hyperventilation
- Seizure prophylaxis
- Reversal of anticoagulants if applicable
- Close monitoring for signs of declining neurological status, which may necessitate surgical intervention. The decision for surgical evacuation would depend on factors such as the thickness of the hematoma, presence of midline shift, and the patient's neurological status, with definitive treatment typically involving surgical evacuation for hematomas causing significant mass effect or in patients with declining neurological status, as guided by the principles outlined in the management of acute subdural hematomas 1.
From the Research
Management Plan for Suspected Acute Subdural Hematoma
The patient's condition, as described, indicates a suspected acute subdural hematoma without mass effect, parenchymal bleed, midline shift, herniation, or ventricular trapping. The management plan for such a patient can be outlined as follows:
- Initial Assessment and Stabilization: The initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, focusing on maintaining optimal intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), and oxygenation levels 2.
- Imaging and Diagnosis: The use of computed tomography (CT) of the head is crucial for determining the location, size of the hematoma, and presence of midline shift. Immediate laboratory workup must include coagulation studies and platelet count to identify any coagulopathy or bleeding diathesis that may require reversal 3.
- Surgical Evaluation: Immediate neurosurgical evaluation is necessary to determine if the hematoma warrants surgical evacuation. The decision for urgent or emergent surgical evacuation is influenced by neurologic examination, imaging characteristics, and the presence of mass effect or elevated ICP 3.
- Medical Management: Medical management focuses on:
- Management of intracranial hypertension
- Maintenance of adequate cerebral perfusion
- Seizure prevention and treatment
- Maintenance of normothermia, eucarbia, euglycemia, and euvolemia
- Early initiation of enteral feeding, mobilization, and physical therapy 2
- Specific Considerations: For patients with acute subdural hematoma and clot thickness <10 mm and midline shift <5 mm, specific considerations of neurologic findings and clinical circumstances will guide the management plan. The role of prophylactic antiepileptic drugs may be considered, especially in cases of acute-on-chronic subdural hematoma, given the high risk of acute symptomatic seizures and unfavorable outcomes 4.
- Postoperative Care: Postoperative management includes monitoring for resolution of pneumocephalus, mobilization, drain removal, and monitoring for signs of hematoma reaccumulation. Medical considerations include seizure prophylaxis, management, and resumption of antithrombotic and anticoagulant medication 3.
Key Factors Influencing Outcome
Several factors can influence the outcome in patients with acute subdural hematoma, including:
- Mechanism of injury
- Age over 65 years
- Admission Glasgow Coma Scale (GCS) score
- Postoperative ICP
- Presence of mass effect or elevated ICP
- Timing of operative intervention, although the evidence suggests that the extent of primary underlying brain injury may be more critical than the timing of subdural blood removal 5