What is the management of subdural hematoma?

Management of Subdural Hematoma

Immediate Surgical Evacuation is Indicated for Symptomatic Cases

For symptomatic subdural hematomas with significant mass effect, neurological deterioration, or decreased level of consciousness, immediate surgical evacuation is the standard of care. 1

Initial Assessment and Surgical Triage

The decision for surgical intervention depends on three critical factors that must be assessed immediately:

• Neurological status: Measure Glasgow Coma Scale (GCS), perform pupillary examination (bilateral abnormal pupils strongly predict poor outcome), and document focal neurological deficits 1, 2
• Hematoma characteristics on CT: Measure maximal thickness, degree of midline shift, and density pattern (acute vs chronic vs mixed) 1
• Clinical stability: Assess for progressive symptoms including headache, altered consciousness, and vomiting 1

Surgical Indications and Timing

Acute Subdural Hematoma (Traumatic)

Operate immediately if any of the following are present:

• Neurological deterioration or decreased level of consciousness 1, 3
• Significant mass effect with midline shift 1
• GCS ≤8 with abnormal pupils (though this predicts worse outcomes regardless of intervention) 2

Critical caveat: While earlier surgery has been traditionally advocated, the extent of underlying brain injury is more important than timing alone in determining outcome. 4 A large study of 101 acute subdural hematomas found no statistically significant difference in mortality based on time to surgery, even when examined at hourly intervals, though trends favored earlier intervention. 4 The ability to control intracranial pressure postoperatively is more critical than the absolute timing of clot removal. 4

Chronic Subdural Hematoma

Burr hole drainage is the preferred first-line surgical approach for chronic subdural hematomas, with subdural drain placement to reduce recurrence rates. 1, 5 A meta-analysis of 34,829 patients demonstrated that percutaneous bedside twist-drill drainage is equally effective as operating room burr hole evacuation, with no significant differences in mortality (RR 0.69,95% CI 0.46-1.05), morbidity (RR 0.45,95% CI 0.2-1.01), cure rates (RR 1.05,95% CI 0.98-1.11), or recurrence rates (RR 1.0,95% CI 0.66-1.52). 5

Surgical Technique Selection

For Acute Subdural Hematoma:

• Craniotomy or decompressive craniectomy are both acceptable, though craniectomy is associated with higher initial complication rates (RR 1.39,95% CI 1.04-1.74) 5
• The choice depends on degree of brain swelling and ability to achieve adequate decompression 3

For Chronic Subdural Hematoma:

• Burr hole drainage with subdural drain placement significantly reduces recurrence rates (RR 0.46,95% CI 0.27-0.76) 5
• Craniotomy should be reserved for recurrent cases after failed minimally invasive procedures (RR 0.22,95% CI 0.05-0.85 for recurrence management) 5

Conservative Management Strategy

For stable patients without significant neurological deficits, particularly small or asymptomatic hematomas, conservative management with close monitoring is appropriate. 1, 6

Conservative management requires:

• Regular neurological assessments (at least every 4 hours initially) 6
• Maintain euvolemia to optimize cerebral perfusion (avoid hypervolemia as it does not improve outcomes) 1, 6
• Serial imaging to monitor for progression 1

Transition to surgery if any of the following develop:

• Neurological deterioration 1, 6
• Increased intracranial pressure refractory to medical management 6
• Progressive mass effect or midline shift on repeat imaging 6

Anticoagulation Management

For patients on anticoagulation who develop subdural hematoma, rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K. 1 The duration of anticoagulation interruption is typically 7-15 days, with low risk of ischemic events during this period. 1

Important note: Patients on oral antithrombotic therapy do not have worse outcomes compared to those not on such therapy, so anticoagulation status alone should not preclude surgical intervention. 2

Adjuvant Therapies to Avoid

Do not use corticosteroids as adjuvant therapy for subdural hematoma management. A meta-analysis demonstrated higher morbidity with corticosteroid use (RR 1.97,95% CI 1.54-2.45) with no significant improvement in recurrence or cure rates. 5

Special Considerations

Age

Advanced age alone should not preclude surgical intervention. 6 While 74% of patients in one series were older than 65 years, age was not a predictive factor for outcome. 2

Poor Prognostic Indicators

The following factors predict worse outcomes but should not automatically exclude patients from surgery:

• Bilateral abnormal pupils (strongest predictor of poor outcome and loss of independence) 2
• GCS ≤8 at admission 2
• Male gender (associated with lower probability of achieving independent living) 2
• Postoperative intracranial pressure >45 mmHg 4

Non-Traumatic Subdural Hematoma

Consider ruptured intracranial aneurysm as a cause of non-traumatic subdural hematoma, particularly if occurring without subarachnoid hemorrhage. 7 Perform cerebral angiography if no clear traumatic etiology exists, and secure the aneurysm before or during hematoma evacuation. 7

Critical Pitfalls to Avoid

• Never delay surgical intervention when neurological deterioration occurs, as this leads to poorer outcomes 1
• Do not use hypervolemia in management, as it does not improve outcomes and may cause complications 1, 6
• Do not rely solely on timing to surgery as the primary determinant of outcome in acute subdural hematoma; focus on controlling intracranial pressure postoperatively 4
• Always place a subdural drain when performing burr hole drainage for chronic subdural hematoma to reduce recurrence 1, 5