Inpatient Management of Subdural Hemorrhage
Initial Care Setting and Monitoring
All patients with subdural hemorrhage should be admitted to a specialized neurocritical care or stroke unit with multidisciplinary team care, as this approach significantly reduces mortality and improves functional outcomes compared to general ward admission. 1
Intensive care unit (ICU) admission is mandatory for:
Step-down unit or lower-level monitoring may be appropriate for:
Neurological Monitoring Protocol
Implement hourly neurological assessments during the first 48 hours, as the highest risk period for deterioration occurs within the first 12 hours after hemorrhage. 1
Airway and Respiratory Management
Secure the airway with endotracheal intubation if GCS ≤8 or signs of increased intracranial pressure are present. 2
- Maintain end-tidal CO₂ monitoring continuously to avoid hypocapnia-induced cerebral vasoconstriction and ischemia 1
- Target PaO₂ >60 mmHg 5
- Avoid hyperventilation unless treating acute herniation, as it causes cerebral ischemia 1
Hemodynamic Management
Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg and mean arterial pressure (MAP) 80-110 mmHg. 4, 6, 5
Critical thresholds to avoid: 6
Avoid hypotension aggressively, as it worsens secondary brain injury 5
Coagulopathy Reversal
Emergency reversal of anticoagulation must be performed immediately in patients with subdural hemorrhage. 1
- Initiate reversal before transfer if interhospital transport is required, but do not delay transfer if reversal agents are unavailable 1
- Follow institutional protocols based on specific anticoagulant (warfarin, direct oral anticoagulants, heparin products) 1
- The 2016 Neurocritical Care Society guidelines provide detailed reversal strategies for each agent class 1
Seizure Management
Administer anti-seizure medications prophylactically in high-risk patients, but avoid phenytoin due to associated excess morbidity and mortality. 1, 5
- High-risk features include: cortical involvement, depressed skull fracture, penetrating injury, or early post-traumatic seizure 5
- Alternative agents (levetiracetam, valproate) are preferred over phenytoin 1
Medical Supportive Care
Maintain strict physiological homeostasis to prevent secondary brain injury: 5
- Normothermia: Avoid fever aggressively 5
- Euglycemia: Prevent both hyper- and hypoglycemia 5
- Euvolemia: Avoid hypovolemia; prophylactic hypervolemia is not beneficial and potentially harmful 1
- Eucarbia: Maintain normal PaCO₂ unless treating acute herniation 5
Venous Thromboembolism Prophylaxis
Once the subdural hemorrhage is stable on repeat imaging (typically after 24-48 hours), initiate mechanical VTE prophylaxis followed by pharmacological prophylaxis. 1
- Begin with pneumatic compression devices immediately 1
- Pharmacological prophylaxis timing remains controversial; individualize based on hemorrhage stability and surgical intervention 7
- When aneurysm or vascular lesion is secured (if applicable), VTE prophylaxis should be used 1
Nutrition and Mobilization
Initiate early enteral feeding and physical therapy as soon as medically stable. 5
- Early mobilization protocols improve outcomes but must be balanced against fall risk 1
- Nurse-driven mobility programs can safely increase mobilization frequency 1
Surgical Decision-Making
Urgent neurosurgical consultation is mandatory for: 1, 4
- Acute subdural hematoma with thickness >5mm AND midline shift >5mm 1, 4
- Any symptomatic subdural hematoma causing neurological decline 1
- GCS ≤8 with significant mass effect 4
- Progressive neurological deterioration despite medical management 5
Surgical evacuation should be performed as soon as possible after the decision is made, as delays worsen outcomes in patients with significant mass effect and low GCS. 4
Post-Operative Management
After surgical evacuation, continue ICU-level neurocritical care with ICP monitoring if any of the following were present preoperatively: 6
- Motor response ≤5 on GCS 6
- Anisocoria or bilateral mydriasis 2, 6
- Hemodynamic instability 6
- Severe imaging findings 6
- Intraoperative cerebral edema 6
Common Pitfalls to Avoid
- Do not delay neuroimaging in any patient with suspected subdural hemorrhage, even with subtle symptoms 2
- Do not admit small isolated subdural hemorrhages (<10 cm³) with stable examinations to ICU unnecessarily, as this wastes resources without improving outcomes 3
- Do not perform routine repeat CT scans beyond 24 hours in neurologically stable patients, as yield is extremely low 1
- Do not use prophylactic hypervolemia to prevent complications, as it provides no benefit over normovolemia and may cause harm 1
- Do not overlook ICP monitoring indications after hematoma evacuation in patients with preoperative anisocoria or severe injury 2, 6
- Do not delay surgical intervention in patients with significant mass effect (>5mm thickness, >5mm midline shift) and neurological compromise, as timing directly impacts mortality in this subset 4, 8