What is the management approach for a subacute dural hematoma?

Management of Subacute Dural Hematoma

The management of subacute dural hematoma requires surgical evacuation when the hematoma thickness exceeds 5 mm with displacement of the median line greater than 5 mm, or when neurological deterioration occurs. 1

Initial Assessment and Management

• Immediate neuroimaging with non-contrast CT scan is essential to characterize the size, location, and mass effect of the hematoma 2
• Complete neurological assessment using Glasgow Coma Scale (GCS), pupillary examination, and evaluation of focal neurological deficits is crucial 2
• Verification of anticoagulant or antiplatelet use is important as these medications increase the risk of hematoma expansion 2
• Secure airway with tracheal intubation and mechanical ventilation with end-tidal CO₂ monitoring in patients with severe traumatic brain injury 1

Indications for Surgical Intervention

• Surgical evacuation is indicated for:
  • Significant subdural hematoma with thickness greater than 5 mm and midline shift greater than 5 mm 1, 3
  • Neurological deterioration or GCS score decrease of 2 or more points 3
  • Development of signs of intracranial hypertension or significant mass effect 2
  • Asymmetric or fixed and dilated pupils 3
  • Intracranial pressure exceeding 20 mm Hg in monitored patients 3

Surgical Options

• Craniotomy with or without bone flap removal and duraplasty is the preferred surgical approach for subacute subdural hematomas with significant mass effect 3
• Burr hole evacuation may be considered for less severe cases, particularly in elderly patients or those with higher surgical risk 4
• Decompressive craniectomy may be considered in cases of refractory intracranial hypertension, particularly in younger patients (typically under 65-70 years) 1
• For patients who cannot tolerate general anesthesia, twist drill craniostomy or subdural evacuating port system (SEPS) placement under local anesthesia may be considered 4, 5

Post-Surgical Management

• Intracranial pressure monitoring is recommended for all comatose patients (GCS score less than 9) 3
• Maintain euvolemia and avoid hypovolemia to optimize cerebral perfusion 2, 6
• Consider subdural drain placement during surgery to reduce recurrence rates 6
• Monitor for complications including seizures, infection, and hematoma expansion 2
• Early rehabilitation should be initiated to prevent complications related to immobility 2

Non-Surgical Management

• Conservative management may be considered when:
  • There are no signs of intracranial hypertension or neurological deterioration 2
  • The hematoma is small with minimal mass effect 2
• Close neurological observation with serial assessments of GCS, pupils, and focal deficits is essential 2
• Repeat CT scan at 24 hours is recommended, especially in patients on anticoagulants 2

Special Considerations

• Elderly patients require careful monitoring as small hematomas can expand rapidly, especially in those on anticoagulants 2
• Patients on anticoagulants or antiplatelet therapy require special consideration regarding reversal of these medications prior to surgical intervention 6
• Timing of surgery is critical - surgical evacuation should be performed as soon as possible when indicated 3
• External ventricular drainage may be considered to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1

Pitfalls to Avoid

• Delaying surgical intervention in symptomatic patients can lead to neurological deterioration and poorer outcomes 6
• Underestimating small hematomas in elderly patients, especially those on anticoagulants 2
• Hypervolemia in the postoperative period does not improve outcomes and may lead to complications 6
• Hypocapnia should be avoided as it induces cerebral vasoconstriction and increases risk of brain ischemia 1