What are the drugs and dosages used for managing subdural hematoma (SDH)?

Medical Management of Subdural Hematoma (SDH)

The primary pharmacological management for subdural hematoma focuses on controlling intracranial pressure, preventing seizures, and managing cerebral edema, with dexamethasone at 4-8 mg/day being the first-line treatment for cerebral edema and antiepileptic drugs only recommended for patients with a history of seizures or those undergoing surgery. 1

Initial Medical Management

• Dexamethasone is recommended at starting doses of 4-8 mg/day for management of perilesional vasogenic edema associated with subdural hematomas 1
• For patients with more acute neurologic deterioration, higher dexamethasone doses approaching 100 mg/day in divided doses can be considered 1
• Steroid dose should be tapered as quickly as the clinical situation allows due to toxicity associated with long-term (>3 weeks) use 1
• For patients with incidentally discovered SDH without significant mass effect or edema, withholding steroids may be appropriate 1

Seizure Management

• Prophylactic anticonvulsants should only be administered to patients at risk for seizure (those with history of seizures or undergoing surgery) 1
• When anticonvulsants are needed, non-enzyme-inducing agents should be used whenever possible to avoid impacting metabolism of chemotherapy and steroids 1
• Common first-line anticonvulsant agents include phenytoin, carbamazepine, levetiracetam, and valproic acid 1
• If anticonvulsants are started in preparation for surgery, discontinuation can be strongly considered after the perioperative period 1

Management of Intracranial Hypertension

• Initial management should focus on maintaining intracranial pressure (ICP) <22 mmHg and cerebral perfusion pressure (CPP) >60 mmHg 2
• Mean arterial pressure (MAP) should be maintained between 80-110 mmHg 2
• In adults with traumatic SDH, systolic blood pressure should be maintained >110 mmHg prior to measuring cerebral perfusion pressure 1
• Rapid correction of arterial hypotension should include vasopressor drugs such as phenylephrine and norepinephrine 1

Anticoagulation Management

• For patients on anticoagulation who develop SDH, the INR should be rapidly reversed using clotting factors, vitamin K, and/or fresh frozen plasma 1
• Prothrombin complex concentrate normalizes the INR within 15 minutes of administration and is preferred over fresh frozen plasma for serious bleeding 1
• Vitamin K should be administered in combination with either product to maintain the beneficial effect 1
• The appropriate duration of interruption of anticoagulation among high-risk patients should be carefully considered, weighing the risks of thromboembolic events against the risk of recurrent hemorrhage 1

Special Considerations for Subdural Hygroma

• For subdural hygromas associated with spontaneous intracranial hypotension (SIH), epidural blood patch should be prioritized as initial treatment 3
• Small or asymptomatic hygromas should be managed conservatively while treating any underlying CSF leak 3
• Patients should be advised to maintain bed rest in supine position as much as possible 3
• For symptomatic hygromas with significant mass effect, burr hole drainage should be performed in conjunction with treating any underlying CSF leak 3

Monitoring and Critical Care Management

• Ventilation should be controlled throughout tracheal intubation with end-tidal CO2 monitoring to maintain appropriate PaCO2 levels 1
• Maintenance of normothermia, eucarbia, euglycemia, and euvolemia is essential in the medical management of SDH 2
• Early initiation of enteral feeding, mobilization, and physical therapy should be implemented 2
• Post-operatively, SDH patients require ICU level care with expertise in treating increased intracranial pressure, seizures, and status epilepticus 2

Complications to Monitor

• Expansion of subdural hematomas, particularly in the subacute stage (4-21 days after trauma) 4
• Cerebral venous thrombosis, especially in cases associated with spontaneous intracranial hypotension 3
• Superficial siderosis in cases of persistent CSF leaks 3

Surgical Indications

• Removal of a significant acute subdural hematoma (thickness greater than 5 mm with displacement of the median line greater than 5 mm) 1
• For patients with minimal symptoms (Glasgow Coma Scale scores of 11-15) and small SDHs (≤1 cm), nonsurgical management may be appropriate 5
• Minimal trephination with closed-system drainage can be used to manage expanding subacute SDHs 4