What is the treatment for a subdural hematoma?

Treatment of Subdural Hematoma

Surgical evacuation is the primary treatment for significant acute subdural hematomas, particularly those with thickness greater than 5 mm and midline shift greater than 5 mm, regardless of Glasgow Coma Scale score. 1

Initial Management

Immediate Stabilization

• Secure airway and control ventilation with endotracheal intubation and mechanical ventilation
• Monitor end-tidal CO2 to maintain appropriate PaCO2 1
• Control blood pressure with a target systolic BP <140 mmHg within 6 hours of onset 2
• Correct coagulopathy immediately:
  • Reverse anticoagulants (prothrombin complex concentrate preferred over fresh frozen plasma) 1, 2
  • Consider platelet transfusion for patients on antiplatelet therapy 2
  • Administer vitamin K in combination with reversal agents 1

Neurological Assessment and Monitoring

• Perform rapid neuroimaging with CT to confirm diagnosis 2
• Monitor intracranial pressure (ICP) in patients with severe traumatic brain injury 1
• Maintain cerebral perfusion pressure (CPP) >60 mmHg 2
• Consider osmotherapy with mannitol or hypertonic saline for ICP management 2

Surgical Intervention

Indications for Surgery

• Acute subdural hematoma with thickness >5 mm and midline shift >5 mm 1
• Patients with neurological deterioration 2
• GCS score of 9-12 with hematoma extending to within 1 cm of cortical surface 2

Surgical Approaches

1. Large Craniotomy:

   • Standard approach for acute subdural hematomas 3
   • Can be easily converted to decompressive craniectomy if brain swelling occurs 3
   • Recommended size: fronto-parieto-temporo-occipital craniectomy up to midline with diameter ≥12 cm 2

2. Decompressive Craniectomy:

   • Indicated for patients with coma, large hematomas, significant midline shift, or elevated ICP refractory to medical management 2
   • Includes durotomy and enlargement duroplasty 2
   • Consider for refractory intracranial hypertension after multidisciplinary discussion 1

3. Minimally Invasive Techniques:

   • Subdural Evacuating Port System (SEPS) may be used in emergency settings or as a temporizing measure 4, 5
   • Particularly useful in outlying areas with limited neurosurgical coverage 4
   • Small craniotomy or endoscopic burr-hole evacuation may be considered for poor surgical candidates 3

Timing of Surgery

• Immediate surgical intervention for patients with neurological deterioration 2
• In selected elderly patients with good neurological exam, delayed intervention (allowing ASDH to become chronic) may be considered to reduce surgical risk 6
• Early intervention (within 24-48 hours) is generally associated with better outcomes 2

Postoperative Management

• Continue ICP and CPP monitoring with treatment of intracranial hypertension 2
• Perform control CT after 24 hours or earlier if signs of intracranial hypertension develop 2
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin from the second postoperative day 2
• Use intermittent pneumatic compression for prevention of venous thromboembolism beginning on day of admission 2
• Screen for dysphagia before initiating oral intake 2
• Monitor glucose and avoid both hyperglycemia and hypoglycemia 2
• Treat clinical seizures with antiseizure medications 2
• Begin early rehabilitation in the ICU 2

Prognostic Factors

• Poor prognostic factors include:
  • Larger hematoma volume
  • Lower initial GCS score
  • Presence of intraventricular hemorrhage 2
• Better outcomes observed in younger patients (<60 years) 2
• 30-day mortality rate for intracerebral hemorrhage: 35-52% 2
• Only about 20% of patients achieve functional independence after 6 months 2

Special Considerations

• For anticoagulated patients, rapid reversal of anticoagulation is essential before surgical intervention 1, 2
• When restarting anticoagulation after hemorrhage, carefully weigh risks of recurrent hemorrhage against thromboembolic events 1
• In rare cases of hyperacute subdural hematoma with mixed-density components on CT, SEPS placement may serve as a bridge to definitive surgical treatment 5

The management of subdural hematomas requires prompt decision-making and often surgical intervention to improve mortality and functional outcomes. The specific approach should be determined based on hematoma characteristics, patient condition, and available neurosurgical expertise.