Management of Epidural Hematoma and Subdural Hematoma
Prompt surgical evacuation is the standard of care for symptomatic epidural hematomas, while management of subdural hematomas should be based on clinical presentation, neurological status, and imaging findings. 1
Initial Assessment and Management
- Rapid neurological assessment is essential, with particular attention to Glasgow Coma Scale (GCS) score, as lower preoperative GCS is an independent risk factor for poor prognosis 2
- Immediate neuroimaging with CT or MRI should be performed to confirm diagnosis and determine hematoma size, location, and mass effect 3
- In patients on anticoagulants, rapid normalization of coagulation status is mandatory to prevent hematoma expansion 4
- For patients with coagulopathy, aim for platelet count above 100 × 10⁹/L before surgical intervention 5
Epidural Hematoma Management
Surgical Management
- Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo immediate surgical evacuation 1
- Symptomatic epidural hematomas require prompt evacuation to achieve optimal outcomes 3
- Consider early decompression with burr-hole craniotomy followed by decompressive craniectomy for gradual decompression in severe cases 2
Conservative Management
- Small, asymptomatic epidural hematomas may be managed conservatively with careful neurological observation and repeat imaging 6
- Risk factors for deterioration requiring subsequent evacuation include:
- Skull fracture overlying a major vessel or sinus (55% deterioration rate)
- Diagnosis within 6 hours of trauma (43% deterioration rate)
- Presence of both risk factors (71% deterioration rate) 6
- Patients without these risk factors have a lower risk of delayed deterioration (13%) 6
Subdural Hematoma Management
Acute Subdural Hematoma
- Surgical evacuation is indicated for:
- The STICH trial found that patients with hematomas extending to within 1 cm of the cortical surface had a trend toward more favorable outcomes with surgery within 96 hours 1
Chronic Subdural Hematoma
- Small or asymptomatic subdural hematomas can be managed conservatively while treating any underlying cause 1
- Symptomatic hematomas with significant mass effect may need burr hole drainage 1
- Non-surgical management may be appropriate for fully conscious patients with close neurological observation 7
Special Considerations
Anticoagulation Management
- In patients with intracranial hemorrhage and elevated INR, rapid normalization of coagulation is essential 4
- 30-40% of intracranial hemorrhages expand during the first 12-36 hours, which is associated with neurological worsening 4
- Options for anticoagulation reversal include:
- Prothrombin complex concentrate (PCC) - preferred when available
- Fresh frozen plasma (FFP) - acceptable alternative
- Vitamin K administration alongside FFP to maintain coagulation correction 4
Thromboprophylaxis
- Consider thromboprophylaxis once hemostasis is secured to prevent thromboembolic complications 5
- For patients with mechanical heart valves, anticoagulation can typically be resumed after 7-10 days if repeat imaging shows no expansion 4
Spinal Epidural and Subdural Hematomas
- Spinal subdural hemorrhages are more common than epidural in the thoracic spine 8
- Epidural hemorrhages are frequently located dorsal to the spinal cord due to tight fixation of the dura to vertebral bodies 8
- MRI is the diagnostic modality of choice for spinal hematomas 8
Post-Treatment Management
- Close neurological monitoring is essential during the recovery period 4
- Repeat imaging should be performed to assess for hematoma resolution or expansion 6
- Rehabilitation should be considered to optimize functional recovery 1
- The coordination of care between specialists is essential for optimal outcomes 1