What is the medical management of Epidural Hematoma (EDH), Subdural Hematoma (SDH), and brain contusion?

Medical Management of Epidural Hematoma (EDH), Subdural Hematoma (SDH), and Brain Contusion

The medical management of traumatic brain injuries including EDH, SDH, and brain contusions requires immediate intervention focused on preventing secondary brain injury, controlling intracranial pressure, and maintaining adequate cerebral perfusion to optimize patient outcomes.

Initial Assessment and Management

• Perform rapid neurological assessment including Glasgow Coma Scale (GCS), pupillary examination, and vital signs monitoring 1
• Maintain airway, breathing, and circulation according to Emergency Neurological Life Support (ENLS) guidelines 2
• Obtain urgent non-contrast head CT as the preferred initial imaging modality to identify acute intracranial hemorrhage 3
• Target the following physiological parameters:
  • Intracranial pressure (ICP) < 22 mmHg
  • Cerebral perfusion pressure (CPP) > 60 mmHg
  • Mean arterial pressure (MAP) 80-110 mmHg
  • PaO2 > 60 mmHg 2

Specific Management for EDH

• Surgical evacuation is indicated for:
  • EDH thickness > 10 mm
  • Midline shift > 5 mm
  • Any EDH with neurological deterioration 4
• For non-surgical EDH (small volume, minimal symptoms):
  • Close neurological monitoring with serial examinations
  • Repeat head CT within 6-24 hours to assess for expansion 5
• Consider decompressive craniectomy for EDH with associated massive brain swelling to improve outcomes 5

Specific Management for SDH

• Surgical evacuation is indicated for:
  • SDH thickness > 10 mm
  • Midline shift > 5 mm
  • GCS decrease of ≥ 2 points
  • Asymmetric or fixed/dilated pupils
  • ICP > 20 mmHg despite medical management 6
• For non-surgical SDH:
  • ICP monitoring for all comatose patients (GCS < 9)
  • Serial neurological examinations
  • Repeat head CT within 6-24 hours 6
• Be vigilant for development of contralateral EDH after decompressive surgery for acute SDH, especially in patients with contralateral skull fracture 7

Specific Management for Brain Contusions

• Surgical intervention (contusion necrotomy) may be required for progressive elevation in ICP and clinical deterioration 4
• Medical management includes:
  • ICP monitoring and management
  • Maintenance of adequate CPP
  • Prevention of secondary brain injury 2
• Serial imaging to monitor contusion progression, as contusions can expand over 24-48 hours 1

Medical Therapies for All Traumatic Brain Injuries

Seizure Management

• Administer antiepileptic prophylaxis for high-risk patients (consider for 7 days post-injury) 3
• Levetiracetam is preferred over phenytoin due to better tolerability and fewer drug interactions 8, 3
• Early post-traumatic seizures occur in approximately 2.2% of all TBI cases, but incidence is higher in severe TBI 8, 9
• Consider continuous EEG monitoring in patients with depressed mental status disproportionate to their brain injury 8, 3

ICP Management

• Elevate head of bed to 30 degrees 2
• Maintain normothermia, eucarbia, euglycemia, and euvolemia 2
• Consider osmotic therapy (mannitol or hypertonic saline) for elevated ICP 2
• Avoid high-dose glucocorticoids as they are not recommended after severe TBI 9
• Use the consensus-derived matrix for de-escalation of ICP therapy based on clinical status and imaging findings 1

Hemostasis Management

• Reverse anticoagulation or antiplatelet medications if neurosurgical intervention is anticipated 2
• Consider prothrombin complex concentrate, vitamin K, or platelet transfusion as appropriate 2

Supportive Care

• Early initiation of enteral feeding to meet nutritional requirements 2
• Early mobilization and physical therapy when hemodynamically stable 2
• Prevention of common ICU complications (DVT, pneumonia, etc.) 2

Monitoring and Follow-up

• Serial neurological examinations to detect early deterioration 3
• Follow-up head CT within 24 hours or sooner if neurological deterioration occurs 3
• ICP monitoring for patients with GCS < 9 and abnormal CT findings 6
• Use the decision-support matrix for therapy de-escalation based on Marshall CT classification, GCS motor score, and pupillary examination 1

Important Considerations and Pitfalls

• Beware of delayed hemorrhage or expansion of contusions within the first 24-48 hours 1
• Monitor for development of contralateral hematomas after decompressive surgery, especially in patients with skull fractures 7
• Consider MRI for better detection of diffuse axonal injury and microhemorrhages, though less practical in acute settings 1, 3
• Surgical approaches vary significantly between centers, with substantial variation in practice patterns for acute SDH management 1