What is the management of subdural hematoma (SDH)?

Management of Subdural Hematoma (SDH)

Surgical intervention is indicated for acute subdural hematomas with thickness greater than 5 mm and midline shift greater than 5 mm, while conservative management is appropriate for stable SDHs without significant neurological deficits. 1, 2

Types of SDH and Initial Assessment

• Assess Glasgow Coma Scale (GCS), pupillary examination, and detailed neurological examination to establish baseline status 2
• Evaluate for symptoms such as headache, altered consciousness, vomiting, and focal neurological deficits 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 3

Management Algorithm

Acute SDH

• Surgical Indications:

  • SDH thickness > 5 mm with midline shift > 5 mm 1
  • SDH > 10 mm regardless of midline shift 4
  • Rapidly deteriorating neurological exam 4
  • Unilaterally or bilaterally dilated nonreactive pupils 4
  • Extensor posturing 4

• Surgical Options:

  • Craniotomy with clot evacuation for significant mass effect and cerebral edema 4
  • May require craniectomy in severe cases 4

• Conservative Management:

  • For SDH ≤ 3 mm (rarely expand and never require surgery in follow-up) 5
  • For patients with GCS 11-15 without significant neurological deficits or signs of intracranial hypertension 6

Chronic SDH

• Surgical Options:

  • Burr hole drainage as first-line treatment for symptomatic chronic SDH 2
  • Consider placement of subdural drain during surgery to reduce recurrence rates 2
  • Twist drill craniostomy or subdural evacuating port system for patients who cannot tolerate anesthesia 4
  • Craniotomy with or without membranectomy for chronic SDHs that fail conservative management 4

• Conservative Management:

  • For stable patients with no significant neurological deficits 2
  • Maintain euvolemia to optimize cerebral perfusion 2

Risk Factors for SDH Progression

• Larger initial SDH size (especially > 8.5 mm) 5
• Presence of midline shift 7, 5
• Hypertension 5
• Concurrent subarachnoid hemorrhage 5
• Convexity location 5

Medical Management

• Seizure prophylaxis and treatment 3
• Reversal of antiplatelet or anticoagulation medications if neurosurgical intervention is anticipated 3
• Maintenance of normothermia, eucarbia, euglycemia, and euvolemia 3
• Early initiation of enteral feeding, mobilization, and physical therapy 3

Monitoring and Follow-up

• Regular neurological assessments (at least every 4 hours initially) 2
• Serial CT imaging to monitor for hematoma expansion 7
• Monitor for potential complications including cerebral venous thrombosis and progression of mass effect 2

Common Pitfalls to Avoid

• Delaying surgical intervention in case of neurological deterioration can lead to poorer outcomes 2
• Failure to recognize that even initially small SDHs (especially those > 3 mm) can expand and require delayed surgical intervention 7, 5
• Inadequate monitoring of patients with risk factors for hematoma expansion 5
• Overlooking the need for ICU-level care post-operatively for SDH patients 3