What is the management approach for a patient with a subdural (subdural hematoma) hematoma?

Management of Subdural Hematoma

Surgical evacuation is strongly recommended for patients with subdural hematoma who are deteriorating neurologically, have significant mass effect, midline shift, or elevated intracranial pressure (ICP), as this intervention can be life-saving and reduce mortality.1

Indications for Surgical Intervention

Supratentorial Subdural Hematoma

• Immediate surgical evacuation indicated for:
  • Deteriorating neurological status
  • GCS score ≤8 with large hematomas and significant midline shift
  • Elevated ICP refractory to medical management
  • Hematoma thickness ≥10 mm or midline shift ≥5 mm regardless of GCS 1

Cerebellar Subdural Hematoma

• Urgent surgical evacuation recommended for:
  • Neurological deterioration
  • Evidence of brainstem compression
  • Hydrocephalus from ventricular obstruction
  • Cerebellar hematoma volume ≥15 mL 2

Surgical Approaches

Primary Surgical Options

1. Craniotomy with hematoma evacuation

   • Standard approach for acute subdural hematomas
   • Allows direct visualization and complete evacuation
   • Can be converted to decompressive craniectomy if brain swelling occurs 1

2. Decompressive craniectomy

   • Recommended for patients with:
     • Coma
     • Large hematomas with significant midline shift
     • Elevated ICP refractory to medical management
   • May reduce mortality but functional outcome improvement is uncertain 2

3. Minimally invasive techniques

   • Burr-hole evacuation for chronic subdural hematomas
   • Subdural evacuating port system (SEPS) - can be performed at bedside in emergency situations 3
   • Endoscopic evacuation - suitable for selected cases 4

Special Considerations

Coagulation Management

• Correct coagulopathy before surgical intervention
• For patients on anticoagulants: urgent reversal of anticoagulation required
• For thrombocytopenia: platelet transfusion to minimize bleeding risk 1

Timing of Surgery

• While earlier surgery shows trends toward improved outcomes, the extent of primary brain injury and ability to control ICP may be more critical factors than absolute timing 5
• In elderly patients with good neurological exam, delayed intervention (allowing acute to become chronic) may be considered with close neuromonitoring 6

Postoperative Management

• Continuous ICP monitoring for patients with GCS ≤8
• Maintain cerebral perfusion pressure between 50-70 mmHg
• Aggressive treatment of fever
• DVT prophylaxis can be initiated 24-48 hours after documented hematoma stability 1

Outcome Predictors

• Poor prognostic factors include:
  • Age >65 years
  • Admission GCS score of 3 or 4
  • Postoperative ICP >45 mmHg
  • Motorcycle accidents as mechanism of injury 5

Management Algorithm

1. Assess neurological status and imaging findings
2. For acute deterioration or significant mass effect: Immediate surgical evacuation
3. For stable patients with concerning imaging: Close monitoring with serial neurological exams
4. For elderly with good exam: Consider delayed intervention approach
5. For cerebellar hematomas: Lower threshold for surgical intervention due to risk of rapid deterioration

Pitfalls to Avoid

• Delaying surgery in patients with neurological deterioration
• Inadequate correction of coagulopathy before surgery
• Using external ventricular drainage alone for cerebellar hematomas with compression
• Failing to consider decompressive craniectomy when significant brain swelling is present

The management of subdural hematomas requires prompt decision-making based on clinical status, imaging findings, and patient factors, with surgical evacuation being the cornerstone of treatment for patients with significant neurological compromise or mass effect.