What is the treatment for acute subdural hematoma (SDH)?

Treatment of Acute Subdural Hematoma

Surgical evacuation via craniotomy or craniectomy is the definitive treatment for acute subdural hematoma (SDH) with significant mass effect, with rapid reversal of anticoagulation if present. 1

Initial Management

Emergency Assessment and Stabilization

• Follow Emergency Neurological Life Support (ENLS) guidelines:
  • Maintain ICP < 22 mmHg
  • Maintain cerebral perfusion pressure (CPP) > 60 mmHg
  • Maintain MAP 80-110 mmHg
  • Ensure PaO2 > 60 mmHg
  • Rapid sequence intubation if necessary for airway protection 2

Immediate Diagnostic Workup

• CT scan is the first-line imaging modality to diagnose and assess SDH 3
• Laboratory tests: PT, PTT, INR, and platelet count to identify coagulopathy 4

Reversal of Anticoagulation

• For patients on anticoagulants with acute SDH, immediate reversal is crucial 1
• Preferred agents:
  • Prothrombin complex concentrate (PCC): normalizes INR within 15 minutes
  • Vitamin K: administered in combination with PCC for sustained effect
  • Fresh frozen plasma: alternative if PCC unavailable 1, 5

Surgical Management

Indications for Surgical Evacuation

• SDH thickness > 10 mm
• Midline shift > 5 mm
• Neurological deterioration
• Elevated intracranial pressure unresponsive to medical management 4

Surgical Approach

• Craniotomy or craniectomy is preferred over burr holes for acute SDH 4
• The proportion of patients with acute SDH undergoing surgery varies significantly between centers (7-52%), with a median odds ratio of 1.84 1
• The type of surgery also varies between centers:
  • Primary decompressive craniectomies range from 6-67% of cases
  • Craniotomy is the alternative approach 1

Temporizing Measures

• In hyperacute SDH (especially in anticoagulated patients), a subdural evacuation port system (SEPS) may be used as a bridge to definitive surgery 6
• This allows rapid drainage of fresh subdural blood to reduce ICP in critical situations before craniotomy 6

Medical Management

Intracranial Pressure Control

• ICP monitoring is essential in comatose patients
• Osmotic therapy (mannitol or hypertonic saline)
• Head elevation to 30 degrees
• Mild hyperventilation (PaCO2 30-35 mmHg) if needed 2

Seizure Management

• Prophylactic antiseizure medications are recommended in the acute phase
• Continue for 7 days post-injury in high-risk patients 2

Supportive Care

• Maintain normothermia, eucarbia, euglycemia, and euvolemia
• Early initiation of enteral feeding, mobilization, and physical therapy 2
• Thromboprophylaxis within 24 hours after bleeding has been controlled 3

Special Considerations

Anticoagulation Management

• Restart anticoagulation 3-4 weeks after SDH if follow-up imaging shows stability 3
• High-risk patients (mechanical heart valves, atrial fibrillation with high CHA2DS2-VASc score) may consider earlier restart at 2-3 weeks with careful monitoring 3
• Antiplatelet therapy can generally be resumed 4-8 weeks after stabilization 3

Monitoring and Follow-up

• Post-operative CT scan within 24 hours to evaluate for complications and establish a baseline 3
• Monitor for:
  • Signs of reaccumulation of SDH
  • Resolution of pneumocephalus
  • Neurological deterioration 4

Prognostic Factors

The following factors correlate with worse outcomes:

• Age over 65 years
• Initial Glasgow Coma Scale (GCS) score of 3 or 4
• Postoperative ICP greater than 45 mm Hg 7

It's important to note that while timing of surgery has traditionally been emphasized, the extent of primary underlying brain injury and the ability to control ICP may be more critical to outcome than the absolute timing of subdural blood removal 7.