What is the treatment for subdural hematoma with increased Intracranial Pressure (ICP)?

Management of Subdural Hematoma with Increased Intracranial Pressure

Immediate surgical evacuation of the subdural hematoma is the primary treatment for subdural hematoma with increased intracranial pressure (ICP), accompanied by aggressive medical management to control ICP and maintain adequate cerebral perfusion pressure (CPP). 1

Initial Assessment and Monitoring

• ICP Monitoring: Consider ICP monitoring in patients with:

  • Glasgow Coma Scale (GCS) score of 8 or less
  • Clinical evidence of transtentorial herniation
  • Significant intraventricular hemorrhage or hydrocephalus 2

• Target Parameters:

  • Maintain ICP below 20-25 mmHg
  • Maintain CPP above 50-70 mmHg (optimal range 60-90 mmHg) 1, 2
  • Evidence from trauma patients suggests maintaining CPP above 70 mmHg may further improve neurological outcomes 2

• Warning Signs of Elevated ICP:

  • Pupillary changes (unequal, dilated, poorly responsive)
  • Abnormal posturing (decorticate or decerebrate)
  • Decreased level of consciousness
  • Cushing's triad (hypertension with widened pulse pressure, bradycardia, irregular respiratory pattern) - a late sign 1

Medical Management of Elevated ICP

First-Line Interventions

1. Positioning:

   • Elevate head of bed to 30° to improve jugular venous outflow and lower ICP 1

2. Osmotic Therapy:

   • Mannitol: First-line agent for acute ICP elevation

     • Dosage: 0.5-1 g/kg IV bolus over 30-60 minutes
     • May be repeated once or twice as needed if serum osmolality <320 mOsm/L
     • Monitor for volume overload in patients with renal impairment 2, 3

   • Hypertonic Saline: Alternative osmotic agent, especially in hypovolemic patients 1

3. Ventilation Management:

   • Maintain normocapnia (PaCO₂ 35-40 mmHg)
   • Short-term hyperventilation (PaCO₂ 25-30 mmHg) may be used for acute, life-threatening ICP elevations
   • Caution: Prolonged hyperventilation can cause cerebral vasoconstriction and ischemia 2, 1

4. CSF Drainage:

   • Ventricular drainage is appropriate for treating hydrocephalus 2
   • External ventricular drainage can help reduce ICP in patients with intraventricular hemorrhage 1

Second-Line Interventions

1. Sedation and Analgesia:

   • IV sedatives (propofol, midazolam) and analgesics to minimize pain and prevent ICP spikes 1

2. Temperature Control:

   • Maintain normothermia
   • Treat fever aggressively 1

3. Seizure Prophylaxis:

   • Control seizures with appropriate antiepileptic therapy 1

Surgical Management

1. Surgical Evacuation:

   • Urgent surgical evacuation is the definitive treatment for subdural hematoma causing mass effect and increased ICP 1, 4
   • Significant reduction in ICP occurs immediately after bone flap removal, dural opening, and hematoma evacuation 5
   • Initial ICP values >60 mmHg are associated with poor outcomes despite surgical intervention 6

2. Decompressive Craniectomy:

   • Consider for refractory intracranial hypertension 1
   • May be performed with or without hematoma evacuation

Special Considerations

• Blood Pressure Management:

  • Support systemic blood pressure to maintain adequate CPP (>60-70 mmHg) 2
  • Avoid overaggressive treatment of hypertension as it may decrease CPP 2

• Coagulopathy Correction:

  • Correct any coagulopathy prior to invasive procedures or surgery 2

• Monitoring Complications:

  • Watch for rebound intracranial hypertension with repeated mannitol use
  • Monitor for hydroelectrolytic disturbances and renal insufficiency with osmotic therapy 1

Prognosis Factors

• Factors associated with poor outcomes include:

  • Age over 65 years
  • Admission GCS score of 3 or 4
  • Postoperative ICP greater than 45 mm Hg 4
  • Initial ICP greater than 60 mmHg 6

• The ability to control ICP appears more critical to outcome than the absolute timing of subdural blood removal, though earlier surgery tends to improve outcomes 4