What should be the target blood pressure range in a patient with traumatic subdural hematoma and persistent hypertension?

Blood Pressure Management in Traumatic Subdural Hematoma

In patients with traumatic subdural hematoma and persistent hypertension, blood pressure should be maintained with a systolic blood pressure >110 mmHg (and MAP >90 mmHg) but <150 mmHg, especially within 6 hours of symptom onset if immediate surgery is not planned. 1, 2

Target Blood Pressure Parameters

The optimal blood pressure targets for traumatic subdural hematoma management are:

• Systolic blood pressure (SBP): >110 mmHg but <150 mmHg
• Mean arterial pressure (MAP): >90 mmHg
• Cerebral perfusion pressure (CPP): ≥60 mmHg (when ICP monitoring is available)

These targets balance the need to maintain adequate cerebral perfusion while preventing hematoma expansion.

Rationale for Blood Pressure Control

Lower Limit Considerations

• SBP <110 mmHg or MAP <90 mmHg may lead to:
  • Cerebral ischemia
  • Poor neurological outcomes
  • Increased mortality
  • Inadequate cerebral perfusion pressure

Upper Limit Considerations

• SBP >150 mmHg may cause:
  • Hematoma expansion
  • Increased intracranial pressure
  • Secondary brain injury
  • Respiratory distress syndrome
  • Worsened cerebral edema

Management Algorithm

1. Initial Assessment:

   • Establish continuous blood pressure monitoring
   • Consider invasive arterial monitoring with transducer at the level of the tragus for accurate measurements 1

2. Hypertension Management:

   • If SBP >150 mmHg:
     • Increase sedation if patient is intubated
     • Use small boluses of labetalol for blood pressure control 1
     • Target reduction to SBP <150 mmHg, especially within first 6 hours if surgery is not planned

3. Hypotension Management:

   • If SBP <110 mmHg or MAP <90 mmHg:
     • First correct hypovolemia with 0.9% saline (avoid hypotonic solutions) 1, 2
     • If hypotension persists after volume correction, use vasopressors:
       • Small bolus of α-agonist (e.g., metaraminol)
       • Consider norepinephrine infusion (8-12 mcg/min initially) if persistent hypotension 2
       • Note: Norepinephrine should be administered via central venous catheter 1

4. Special Considerations:

   • For small subdural hematomas without signs of elevated ICP: Consider SBP <160 mmHg 2
   • For patients requiring emergency neurosurgery: Maintain SBP >100 mmHg and MAP >80 mmHg 2

Monitoring Parameters

• Continuous blood pressure monitoring (preferably invasive)
• Neurological status (GCS, pupillary response)
• If available, ICP monitoring to calculate CPP (CPP = MAP - ICP)
• Target CPP between 60-70 mmHg 2

Important Caveats

• Avoid excessive fluid resuscitation: High-volume fluid administration (>1,500 ml) is associated with increased mortality 2
• Avoid hypocapnia: Prolonged severe hypocapnia can worsen neurological outcomes 2
• Prioritize bleeding control: Transfer of actively bleeding patients should be delayed until hemorrhage is controlled 1
• Medication caution: Modify sedative and analgesic doses in unstable patients 1

Recent Evidence

A large database study comparing SBP targets of 100-150 mmHg versus <180 mmHg in traumatic subdural hematoma patients found no statistically significant difference in 30-day mortality or secondary outcomes 3. However, current guidelines still recommend tighter control, particularly in the acute phase, to minimize the risk of hematoma expansion 1, 2.