What is the initial management for a small, non-active bleeding subdural hematoma after a fall?

Management of Small Non-Active Bleeding Subdural Hematoma After a Fall

For small, non-active bleeding subdural hematomas after a fall, conservative management with close neurological monitoring is the recommended initial approach, reserving surgical intervention only for cases with neurological deterioration or significant mass effect. 1, 2

Initial Assessment and Imaging

• CT scan is the primary diagnostic tool to confirm subdural hematoma, assess its size, location, and mass effect 1, 2
• MRI with contrast may be considered if spontaneous intracranial hypotension is suspected as an underlying cause 3
• Evaluate for signs of increased intracranial pressure including compression of cisternas basales, ventricular effacement, or midline shift >5mm 4

Management Approach

Conservative Management (First-Line)

• Small, asymptomatic subdural hematomas can be managed conservatively with close neurological monitoring 3, 5
• Conservative management is appropriate when:
  • Patient is fully conscious (GCS 13-15) 6, 5
  • Hematoma is small (≤1 cm thickness) 5
  • No significant mass effect or midline shift 6
  • Basal cisterns are open 5
  • No focal neurological deficits 5

Monitoring Protocol

• Serial neurological examinations to detect early deterioration 2
• Follow-up CT scans to monitor hematoma size and mass effect 6
• Maintain euvolemia to optimize cerebral perfusion 2
• Bed rest may be advised, particularly if there is suspicion of underlying CSF leak 3

Indications for Surgical Intervention

• Development of altered consciousness 2
• New or worsening focal neurological deficits 2, 5
• Significant increase in hematoma size on follow-up imaging 6
• Development of significant mass effect or midline shift 6
• Initial large hematoma volume and midline shift are independent risk factors for eventual surgical evacuation 6

Special Considerations

• Approximately 35% of initially non-operative acute subdural hematomas may eventually require delayed surgical evacuation (median 17 days after trauma) 6
• Patients on anticoagulants or antiplatelet therapy require special consideration regarding medication management 2
• Older patients and those with brain atrophy may tolerate larger hematomas without symptoms 6
• Monitor for development of chronic subdural hematoma, which occurs in approximately 6% of conservatively managed cases 5

Follow-up Recommendations

• Close outpatient follow-up for patients discharged with conservative management 2
• Patient education regarding warning signs requiring immediate medical attention (headache, vomiting, altered consciousness, focal weakness) 2
• Consider repeat imaging at 4-6 weeks to ensure resolution or stability of the hematoma 3

Prognosis

• Patients with small subdural hematomas managed conservatively have favorable outcomes, with functional recovery rates of approximately 93% 5
• Poor prognostic factors include age over 65 years, low initial GCS, and inability to control intracranial pressure if it develops 7