What is the treatment for a subdural hematoma?

Treatment of Subdural Hematoma

Surgical evacuation is the primary treatment for significant acute subdural hematomas, with specific indications including thickness >5 mm, midline shift >5 mm, or neurological deterioration. 1

Initial Management

Immediate Stabilization

• Secure airway, control ventilation with end-tidal CO2 monitoring 1
• Control blood pressure
  • Target systolic BP <140 mmHg within 6 hours of onset 2
  • Maintain cerebral perfusion pressure >60 mmHg 2

Correction of Coagulopathy

• Immediate reversal of anticoagulants before surgical intervention 2
• For patients on:
  • Vitamin K antagonists: Prothrombin complex concentrate + vitamin K 1
  • Direct oral anticoagulants: Specific reversal agents
  • Antiplatelet therapy: Consider platelet transfusion 2

Surgical Management

Indications for Surgical Evacuation

• Acute subdural hematoma with:
  • Thickness >5 mm
  • Midline shift >5 mm
  • Neurological deterioration regardless of imaging findings 1

Surgical Approaches

1. Large Craniotomy

   • First-line approach for most acute subdural hematomas
   • Allows complete evacuation and inspection of underlying brain
   • Can be converted to decompressive craniectomy if brain swelling occurs 3

2. Decompressive Craniectomy

   • Recommended for patients with:
     • Coma
     • Large hematomas
     • Significant midline shift
     • Elevated intracranial pressure refractory to medical management 2
   • Technique: Fronto-parieto-temporo-occipital craniectomy up to midline with diameter ≥12 cm, plus durotomy and duroplasty 2

3. Minimally Invasive Options

   • Subdural Evacuating Port System (SEPS)
     • Bedside procedure useful in emergency settings 4
     • Can serve as temporizing measure before definitive craniotomy 5
     • Particularly valuable in facilities without immediate neurosurgical coverage 4
   • Small craniotomy or endoscopic burr-hole evacuation
     • Suitable for poor surgical candidates 3

Timing of Surgery

• Emergency evacuation for patients with neurological deterioration 1
• For stable elderly patients with good neurological exam, delayed intervention (6-31 days) may be considered to allow hematoma liquefaction, enabling less invasive surgery 6

Postoperative Management

Intracranial Pressure (ICP) Management

• Monitor ICP and cerebral perfusion pressure 2
• Medical management of elevated ICP:
  • Osmotherapy with mannitol or hypertonic saline 2
  • Mannitol works by increasing plasma osmolarity, drawing intracellular water to extracellular space 7

Prevention of Complications

• Thromboembolic prophylaxis with subcutaneous low-dose heparin from second postoperative day 2
• Intermittent pneumatic compression beginning on admission day 2
• Avoid graduated compression stockings 2
• Control blood glucose levels 2
• Formal dysphagia screening before oral intake 2
• Treat clinical seizures with antiseizure medications 2

Follow-up

• Control CT scan after 24 hours or earlier if signs of intracranial hypertension develop 2
• Early rehabilitation initiated in ICU 2

Special Considerations

Pediatric Patients

• Early recognition and immediate surgical intervention may prevent neurological sequelae 8

Elderly Patients

• Higher surgical risk and mortality
• Consider delayed intervention if neurologically stable 6
• 68% of elderly patients can achieve good outcomes (GOS 4-5) with appropriate management 6

Prognosis

• Outcomes vary based on:
  • Initial GCS score
  • Age (better in younger patients)
  • Timing of intervention (early intervention associated with better outcomes) 2
• Between-center variation in surgical management is significant, with the proportion of patients undergoing acute surgery ranging from 7% to 52% 1