From the Guidelines
The management of acute subdural hematoma requires urgent neurosurgical evaluation and often surgical intervention, with primary decompressive craniectomy being a viable option, as evidenced by a recent study published in The Lancet Neurology 1. The goal of treatment is to prevent further brain injury and improve outcomes, with a focus on reducing morbidity, mortality, and enhancing quality of life.
- Key considerations in the management of acute subdural hematoma include:
- Urgent neurosurgical evaluation to determine the need for surgical intervention
- Surgical evacuation via craniotomy or primary decompressive craniectomy for significant hematomas or neurological deficits
- Medical management to prevent secondary brain injury, including intracranial pressure (ICP) control, head elevation, and maintenance of optimal blood pressure and oxygenation
- Seizure prophylaxis with medications such as levetiracetam
- Temperature control, normoglycemia, and adequate oxygenation
- A study published in The Lancet Neurology in 2022 found significant variation in the management of acute subdural hematoma between centers, with a median odds ratio (MOR) of 1.84 for acute surgery and 2.68 for primary decompressive craniectomy 1.
- The management approach should be individualized based on the patient's specific condition, with a focus on minimizing morbidity and mortality, and improving quality of life, as supported by the most recent and highest quality evidence 1.
From the Research
Management of Acute Subdural Hematoma
The management of acute subdural hematoma (ASDH) involves a combination of surgical and non-surgical approaches. The choice of treatment strategy depends on various factors, including the severity of the injury, the patient's age, and the presence of other medical conditions.
Surgical Management
- Decompressive craniectomy and craniotomy are two common surgical procedures used to treat ASDH 2.
- Decompressive craniectomy is often performed in patients with high-energy trauma and a Glasgow Coma Scale (GCS) score of 8 or less 2.
- Craniotomy is also used to evacuate the hematoma and relieve pressure on the brain 3.
- The choice of surgical procedure depends on the individual patient's condition and the surgeon's preference 2.
Non-Surgical Management
- Non-operative management may be considered for patients with a small hematoma and minimal symptoms 4.
- Patients with a GCS score of 3 or less are often considered for surgical intervention, while those with a GCS score of 7 or more may be managed non-operatively 5.
- The use of long-lasting paralytic agents should be avoided to allow for accurate assessment of the patient's neurological status 4.
Predictive Factors of Outcome
- The GCS score at admission is a significant predictor of outcome in patients with ASDH 6, 3, 4, 5.
- Age, presence of antithrombotic therapy, and type of surgical intervention are also important factors that influence outcome 3, 5.
- Male gender and anisocoric pupils are associated with a poorer outcome in patients with ASDH 3.