What is the management approach for Subdural Hematoma (SDH)?

Management Approach for Subdural Hematoma (SDH)

The management of subdural hematoma requires prompt surgical evacuation for acute SDH with thickness >10mm or midline shift >5mm, regardless of Glasgow Coma Scale score, while small asymptomatic hematomas can be managed conservatively with close monitoring. 1

Initial Assessment and Classification

• SDH is classified as acute, subacute, or chronic based on time since injury and imaging characteristics 2
• Initial management follows Emergency Neurological Life Support guidelines, focusing on maintaining ICP <22 mmHg, CPP >60 mmHg, MAP 80-110 mmHg, and PaO2 >60 mmHg 2
• Immediate laboratory workup must include coagulation studies (PT, PTT, INR, platelet count) to identify and correct any coagulopathy 3
• CT scan is the primary imaging modality to determine location, size, midline shift, and presence of other intracranial injuries 3

Surgical Management Criteria

• Surgical evacuation is recommended for:
  • SDH thickness >10mm or midline shift >5mm, regardless of GCS score 1
  • Comatose patients (GCS <9) with SDH <10mm and midline shift <5mm if:
    • GCS decreased by ≥2 points between injury and admission
    • Patient presents with asymmetric or fixed/dilated pupils
    • ICP exceeds 20 mmHg 1
• Surgical evacuation should be performed as soon as possible when indicated 1
• Craniotomy with or without bone flap removal is preferred over burr holes for acute SDH 3

Medical Management

• All comatose patients (GCS <9) with acute SDH should undergo ICP monitoring 1
• Cerebral perfusion pressure should be maintained between 60-70 mmHg in the absence of multi-modal monitoring 4
• For intracranial hypertension, mannitol 20% or hypertonic saline solution at a dose of 250 mOsm can be administered over 15-20 minutes 4
• Seizure prophylaxis should be administered, especially in the acute setting 2
• Anticoagulation or antiplatelet medications should be reversed if neurosurgical intervention is anticipated or until hemorrhage stabilizes on imaging 2

Chronic Subdural Hematoma Management

• Burr-hole drainage with subgaleal drains remains the gold standard for symptomatic chronic SDH 5
• Small or asymptomatic subdural hematomas can be managed conservatively 4
• Middle meningeal artery embolization is an emerging treatment option that may reduce recurrence rates in chronic SDH 5

Post-operative Care

• Patients require ICU-level care with monitoring for:
  • Resolution of pneumocephalus
  • Signs of SDH reaccumulation
  • Management of increased intracranial pressure
  • Seizure control 3
• Patients should be positioned with head elevated as comfortable 4
• Thromboprophylaxis should be considered during immobilization following procedures 4

Follow-up and Monitoring

• Clinical assessment and imaging follow-up are essential to detect reaccumulation or complications 3
• Recurrence remains a principal complication (9-33%), occurring more commonly with older age and bilateral SDHs 5
• Patients should be advised to seek urgent medical attention for new-onset severe headache, neurological deficits, or altered mental status 4

Outcome Considerations

• Recent data suggests that trauma centers with higher rates of surgical intervention for traumatic SDH have lower inpatient mortality and higher odds of favorable discharge 6
• This effect is most pronounced among patients with abnormal pupillary examination findings 6
• The prognosis depends on multiple factors including age, initial GCS, pupillary reactivity, and time to treatment 2