Monitoring Recommendations for Traumatic Subdural Hematoma
Immediate Neurological Assessment
All patients with traumatic SDH require urgent neurological evaluation including pupil examination, Glasgow Coma Scale motor score, and brain CT scan to determine severity of brain damage and guide monitoring strategy. 1
Intracranial Pressure Monitoring Indications
Mandatory ICP Monitoring
Patients with severe traumatic brain injury (GCS ≤8) and abnormal CT scan require ICP monitoring regardless of whether they undergo emergency neurosurgery or extra-cranial surgery. 1, 2
Specific indications for ICP monitoring include:
- Comatose patients (GCS ≤8) with radiological signs of intracranial hypertension 1, 2
- Post-evacuation of traumatic SDH if ANY of the following are present:
High-Risk CT Findings Requiring ICP Monitoring
- Compression of basal cisterns (most important radiological sign) 2
- Ventricular effacement 2
- Midline shift >5 mm 2, 4
- Intracerebral hematoma volume >25 ml 2
- Traumatic subarachnoid hemorrhage 2
When ICP Monitoring is NOT Recommended
Do not place ICP monitor if CT scan is strictly normal without clinical signs of severity, as the incidence of elevated ICP is only 0-8% in this population. 2
Hemodynamic Monitoring Parameters
Blood Pressure Targets
Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions. 1 Lower values may be briefly tolerated only during difficult intraoperative bleeding control. 1
After ICP monitor placement, maintain cerebral perfusion pressure between 60-70 mmHg. 2, 3
- CPP <60 mmHg is associated with worse outcomes 2
- CPP >70 mmHg should be avoided routinely 2
- CPP >90 mmHg worsens neurological outcomes due to vasogenic cerebral edema 2
Respiratory Monitoring
Maintain PaO2 between 60-100 mmHg during all interventions. 1
Maintain PaCO2 between 35-40 mmHg during all interventions. 1
In cases of cerebral herniation, temporary hypocapnia and/or osmotherapy may be used while awaiting emergency neurosurgery. 1
Hematologic Monitoring
Hemoglobin Targets
Transfuse red blood cells for hemoglobin <7 g/dL during interventions. 1 Higher thresholds may be used in elderly patients or those with limited cardiovascular reserve. 1
Coagulation Targets
Maintain platelet count >50,000/mm³ for systemic hemorrhage control. 1
For emergency neurosurgery or ICP probe insertion, maintain higher platelet counts. 1
Maintain PT/aPTT <1.5 times normal control during all interventions. 1
Clinical Monitoring for Non-Operative Management
Criteria for Conservative Management
Patients with GCS 15 and midline shift <10 mm may be managed conservatively with close observation. 4
Patients with GCS <15 can tolerate only minimal midline shift; shifts >5 mm predict exhaustion of compensatory mechanisms within 3 days and require surgical intervention. 4
Serial Monitoring Requirements
Avoid long-acting sedatives and paralytics before arrival at neurosurgical center to allow detection of clinical deterioration. 5
Monitor for GCS score decline between prehospital and admission assessment, as this predicts need for surgical intervention. 5
Perform repeat CT scanning if clinical deterioration occurs. 5
Follow-Up Monitoring
Patients managed conservatively require hospital stay of 6-7 days if fully conscious. 4
Obtain repeat CT before discharge. 4
Provide close outpatient follow-up during first 3-4 weeks. 4
Consider repeat imaging at 4-6 weeks to ensure resolution or stability. 6
Technical Considerations for ICP Monitoring
Intraparenchymal probes are preferred over ventricular catheters due to better risk-benefit profile (infection rate 2.5% vs 10%, hemorrhage rate 0-1% vs 2-4%). 2
Catheter placement failure occurs in 10% of cases. 2