What is the management for a patient diagnosed with a subdural hematoma?

Management of Subdural Hematoma

The management of subdural hematoma requires immediate surgical evacuation via craniotomy or craniectomy for cases with significant mass effect, with rapid reversal of anticoagulation if present, while selected cases with small hematomas and minimal symptoms may be managed conservatively with close monitoring. 1

Initial Assessment and Classification

Diagnostic Approach

• CT scan is the first-line imaging modality to diagnose and characterize subdural hematomas
• Assess for:
  • Hematoma thickness and volume
  • Midline shift
  • Mass effect
  • Associated injuries (contusions, subarachnoid hemorrhage)
  • Signs of increased intracranial pressure

Risk Stratification

• High-risk features requiring urgent intervention:
  • Acute subdural hematoma with mass effect
  • Neurological deterioration
  • Midline shift >5mm
  • Hematoma thickness >10mm 2
  • Obliteration of basal cisterns
  • GCS score <8

Management Algorithm

Surgical Management

1. Indications for immediate surgical evacuation:

   • Acute subdural hematoma with significant mass effect
   • Neurological deterioration
   • GCS score <8 with subdural hematoma
   • Hematoma thickness >10mm
   • Midline shift >5mm

2. Surgical approach:

   • Craniotomy is preferred over burr holes for acute subdural hematomas 1
   • Decompressive craniectomy may be considered for severe cases with significant brain swelling
   • Primary decompressive craniectomies range from 6-67% of cases depending on center practice 1

3. Anticoagulation reversal (if applicable):

   • Immediate reversal is crucial using:
     • Prothrombin complex concentrate (PCC)
     • Vitamin K
     • Fresh frozen plasma 1

Conservative Management

1. Indications:

   • Small acute subdural hematomas (<10mm thickness)
   • No significant mass effect
   • Neurologically intact patient (GCS 14-15)
   • Absence of midline shift 2

2. Monitoring protocol:

   • Serial neurological examinations
   • Follow-up CT scans (initial follow-up within 24 hours)
   • Close observation for at least 24 hours

3. Warning signs requiring surgical intervention:

   • Neurological deterioration
   • Increase in hematoma size
   • Development of mass effect
   • New onset severe headache, confusion, or decreased level of consciousness 1

Critical Care Management

ICP and Hemodynamic Goals

• Maintain ICP <22 mmHg
• Maintain cerebral perfusion pressure (CPP) >60 mmHg
• Target MAP 80-110 mmHg 1

Postoperative Management

• Initial post-operative imaging within 24 hours to evaluate for complications 1
• Monitor for:
  • Rebleeding
  • Development of contralateral hematomas (rare but serious complication) 3
  • Cerebral edema
  • Seizures
  • Hydrocephalus

Thromboprophylaxis

• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled
• Maintain platelet count above 50×10^9/L during acute phase
• Consider mechanical thromboprophylaxis with intermittent pneumatic compression during waiting period 1

Special Considerations

Anticoagulated Patients

• Restart anticoagulation 3-4 weeks after subdural hematoma if imaging shows stability 1
• High-risk patients (high thromboembolic risk) may consider earlier restart at 2-3 weeks with careful monitoring
• Lower-risk patients should wait the full 4 weeks before restarting 1

Pediatric Patients

• Acute subdural hematoma in infants may result from birth trauma or child abuse
• Early surgical intervention may prevent neurological sequelae 4
• Time-critical transfer to pediatric neurosurgical center is appropriate for acute subdural hematoma with mass effect 5

Elderly Patients

• Age >65 years is associated with worse outcomes 6
• Consider comorbidities and frailty in surgical decision-making
• Higher risk of delayed surgical intervention after initial conservative management 7

Follow-up and Rehabilitation

• Activity restrictions:

  • Avoid activities that increase intracranial pressure for 4-6 weeks 1
  • Gradual return to normal activities based on symptom resolution

• Patient education:

  • Warning signs requiring immediate medical attention:
    • New-onset severe headache
    • Confusion
    • Decreased level of consciousness
    • Progressive swelling 1

• Follow-up imaging:

  • Timing based on clinical course and initial management strategy
  • MRI may be considered for better visualization of posterior fossa structures if indicated 1

Prognostic Factors

• Factors associated with poor outcomes:
  • Age >65 years
  • Low admission GCS (especially 3-4)
  • Postoperative ICP >45 mmHg
  • Delayed diagnosis and treatment 6
  • Increased hematoma thickness
  • Low hemoglobin level
  • High leukocyte count 7

The timing of surgical intervention remains controversial, but there is a trend suggesting that earlier surgery improves outcomes, although the extent of primary underlying brain injury appears to be more important than the subdural clot itself in determining prognosis 6.