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 Assessment and Management

1. Immediate Diagnostic Evaluation:

   • Rapid neuroimaging with non-contrast CT is essential to confirm diagnosis and should be completed within 45 minutes of emergency department arrival 1
   • Assess hematoma thickness, midline shift, and neurological status

2. Medical Stabilization:

   • Correct coagulopathy immediately if present:
     • Reverse anticoagulants (prothrombin complex concentrate preferred over fresh frozen plasma)
     • Administer vitamin K in combination with reversal agents 1
   • Control blood pressure with target systolic BP <140 mmHg within 6 hours 1
   • Monitor and maintain:
     • End-tidal CO2 to avoid hypercapnia/hypocapnia
     • Cerebral perfusion pressure >60 mmHg
     • Intracranial pressure (ICP) in severe cases 1

Surgical Management Options

Acute Significant Subdural Hematomas

1. Large Craniotomy:

   • First-line approach for significant acute subdural hematomas
   • Allows complete evacuation and can be converted to decompressive craniectomy if brain swelling occurs 1, 2
   • Important to expose the floor of middle cranial fossa and pay attention to dural sinuses and bridging veins 2

2. Decompressive Craniectomy:

   • Indicated for:
     • Patients with coma
     • Large hematomas
     • Significant midline shift
     • Elevated ICP refractory to medical management 1
   • Technique: Fronto-parieto-temporo-occipital craniectomy up to midline with diameter ≥12 cm, with durotomy and enlargement duroplasty 1

3. Minimally Invasive Options:

   • Small craniotomy or endoscopic burr-hole evacuation may be appropriate for poor surgical candidates 2
   • Subdural Evacuating Port System (SEPS):
     • Can be performed at bedside in emergency situations
     • Useful for hyperacute hematomas with mixed-density components (not fully coagulated)
     • May serve as a temporizing measure before definitive craniotomy 3, 4

Special Considerations

1. Delayed Surgical Intervention:

   • May be considered in select elderly patients with good neurological exam despite meeting surgical criteria
   • Allows hematoma to liquefy, potentially enabling less invasive surgery
   • Requires close neurological monitoring 5

2. Pediatric Cases:

   • Early surgical intervention is crucial in pediatric acute subdural hematomas
   • Prompt craniotomy and evacuation can prevent neurological sequelae 6

Post-Operative Care and Rehabilitation

1. Intensive Monitoring:

   • Initial management in ICU or dedicated stroke unit with neuroscience expertise 1
   • Continued ICP monitoring in severe cases

2. Preventive Measures:

   • Venous thromboembolism prophylaxis with intermittent pneumatic compression (avoid graduated compression stockings) 1
   • Formal dysphagia screening before oral intake
   • Glucose monitoring to avoid hyper/hypoglycemia
   • Treatment of clinical seizures with antiseizure medications 1

3. Rehabilitation:

   • All patients should have access to multidisciplinary rehabilitation 1

Prognostic Factors

• Poor prognostic indicators:

  • Larger hematoma volume
  • Lower initial GCS score
  • Presence of intraventricular hemorrhage
  • Age >60 years 1

• Better outcomes observed in younger patients (<60 years) 1

Common Pitfalls to Avoid

1. Delayed Recognition and Treatment:

   • Failure to obtain prompt neuroimaging in patients with head trauma
   • Delayed surgical intervention in patients meeting surgical criteria with deteriorating neurological status

2. Inadequate Coagulopathy Reversal:

   • Incomplete or delayed reversal of anticoagulation before surgery
   • Failure to administer vitamin K alongside reversal agents

3. Insufficient Decompression:

   • Inadequate size of craniotomy/craniectomy
   • Failure to perform durotomy and duroplasty when indicated

4. Post-Operative Complications:

   • Inadequate ICP monitoring and control
   • Failure to prevent venous thromboembolism
   • Missed seizures requiring treatment

Remember that while minimally invasive techniques like SEPS may be useful in specific scenarios, traditional craniotomy remains the standard of care for significant acute subdural hematomas, with decompressive craniectomy reserved for cases with severe brain swelling or refractory intracranial hypertension.