Management of Subdural Hematoma
Subdural hematomas require urgent neurosurgical evaluation, with surgical evacuation indicated for symptomatic hematomas with significant mass effect, while small or asymptomatic hematomas can be managed conservatively with close monitoring. 1
Initial Assessment and Management
Immediate measures:
- Admit to neuroscience ICU or dedicated stroke unit with continuous monitoring
- Ensure neurosurgical expertise is available within 30 minutes
- Perform frequent neurological assessments using standardized scales (e.g., NIHSS)
- Monitor for deterioration: changes in consciousness, new/worsening focal deficits, pupillary changes 1
Imaging:
- Obtain initial head CT scan to assess hematoma size, location, and mass effect
- Repeat head CT in 6-12 hours or sooner if neurological deterioration occurs 1
Surgical Management
Indications for Urgent Surgical Evacuation:
- Hematoma thickness >10 mm
- Midline shift >5 mm
- Neurological deterioration
- GCS score <9 with pupillary abnormalities
- Intracranial pressure >20 mmHg 2
Surgical Approach:
- Craniotomy with or without bone flap removal is the preferred approach for comatose patients
- Timing is critical - surgical evacuation should be performed as soon as possible when indicated 2
- In some cases, minimally invasive techniques such as the subdural evacuating port system may be considered, especially in remote areas with limited neurosurgical coverage 3
Conservative Management
For small or asymptomatic hematomas:
- Close neurological monitoring
- Blood pressure control (systolic <160 mmHg but >100 mmHg)
- Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available 1
- Repeat imaging to monitor for expansion
Management of Anticoagulation/Antiplatelet Therapy
- Urgent reversal of anticoagulation is indicated for patients with subdural hematoma 1
- Hold antiplatelet agents temporarily
- Target PT/aPTT <1.5 normal control during interventions
- Maintain platelet count >50,000/mm³ (higher values for neurosurgical intervention) 1
- For patients on warfarin with subdural hematoma, rapid reversal of anticoagulation is generally recommended 4
Critical Care Management
Intracranial pressure management:
- Maintain ICP <22 mmHg
- Use stepwise approach for treating elevated ICP
- Consider ICP monitoring for comatose patients 5
Respiratory and hemodynamic goals:
Other supportive measures:
- Seizure prophylaxis in high-risk patients
- Maintain normothermia, euglycemia, and euvolemia
- Early initiation of enteral feeding, mobilization, and physical therapy 5
Common Pitfalls to Avoid
- Delaying neurosurgical consultation
- Inadequate blood pressure control (both hypertension and hypotension worsen outcomes)
- Overlooking coagulopathy correction
- Failing to monitor for hematoma expansion
- Inadequate ICP management 1
Prognosis
Mortality rates for acute subdural hematomas remain high (approximately 66%), with only about 19% achieving functional recovery. Poor prognostic factors include:
- Age over 65 years
- Admission GCS score of 3 or 4
- Postoperative ICP greater than 45 mm Hg
- Underlying brain injury severity 6
While earlier surgery tends to improve outcomes, the extent of primary brain injury and ability to control ICP are often more critical to outcome than absolute timing of hematoma removal 6.