What is the management of intracranial subdural hematoma (SDH) with midline shift?

From the Guidelines

Management of intracranial subdural hematoma with midline shift requires immediate neurosurgical intervention, with a consideration for minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration, with or without thrombolytic use, as it may be useful to reduce mortality and improve functional outcomes, as suggested by the 2022 guideline from the American Heart Association/American Stroke Association 1. The primary treatment is surgical evacuation through craniotomy or burr hole drainage, depending on the hematoma's size, location, and chronicity.

• Patients should be stabilized with airway management, maintaining systolic blood pressure between 100-160 mmHg, and elevating the head of bed to 30 degrees to reduce intracranial pressure.
• Mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) may be administered to reduce cerebral edema while awaiting surgery.
• Anticonvulsant prophylaxis with levetiracetam (500-1000 mg IV twice daily) is often initiated.
• Any anticoagulants should be reversed immediately - for warfarin, administer vitamin K 10 mg IV and prothrombin complex concentrate; for DOACs, use specific reversal agents when available. The 2022 guideline suggests that minimally invasive hematoma evacuation may be considered to improve functional outcomes compared with conventional craniotomy, although the mortality benefit is uncertain 1.
• Post-operatively, patients require ICU monitoring with serial neurological examinations and repeat imaging within 24 hours. The urgency of intervention is critical as midline shift indicates significant mass effect that can lead to herniation, brainstem compression, and death if not promptly addressed.
• The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is supported by the most recent evidence, as stated in the 2022 guideline 1. It is essential to note that the management of intracranial subdural hematoma with midline shift should be individualized, taking into account the patient's specific clinical presentation, hematoma characteristics, and overall medical condition.
• The American Heart Association/American Stroke Association guidelines provide a framework for management, but the decision to perform surgery, and the type of surgery, should be made on a case-by-case basis, considering the potential benefits and risks of each approach 1.

From the FDA Drug Label

Reduction of intracranial pressure and brain mass. The dosage, concentration and rate of administration depend on the age, weight and condition of the patient. Reduction of Intracranial Pressure and Brain Mass: Adults: 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes

The management of intracranial subdural hematoma (SDH) with midline shift may involve the use of mannitol to reduce intracranial pressure and brain mass. The recommended dosage is 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes 2. However, the FDA label does not provide specific guidance on the management of SDH with midline shift, and the use of mannitol in this context should be approached with caution. Key considerations include:

• Monitoring of renal, cardiac, and pulmonary status
• Risk of fluid and electrolyte imbalances
• Potential for CNS toxicity 2

From the Research

Management of Intracranial Subdural Hematoma (SDH) with Midline Shift

The management of intracranial subdural hematoma (SDH) with midline shift involves a combination of medical and surgical interventions.

• Patients with acute or chronic SDHs associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical 3.
• SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative 3.
• Surgical management options include:
  • Twist drill craniostomy and placement of subdural evacuating port system (SEPS) for patients with chronic SDH or those who cannot tolerate anesthesia 3.
  • Burr hole SDH evacuation under conscious sedation or general anesthesia for patients with acute SDH or chronic SDH with septations 3.
  • Craniotomy with clot evacuation and frequently a craniectomy for acute SDH associated with significant mass effect and cerebral edema 3, 4.
  • Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor 5.
• Medical management focuses on:
  • Management of intracranial hypertension 6, 7.
  • Maintenance of adequate cerebral perfusion 6, 7.
  • Seizure prevention and treatment 6, 7.
  • Maintenance of normothermia, eucarbia, euglycemia, and euvolemia 6, 7.
  • Early initiation of enteral feeding, mobilization, and physical therapy 6, 7.
• Post-operative care requires ICU level care and co-management by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness 3, 6, 7.