What is the management of a subdural hematoma after a fall?

Management of Subdural Hematoma After Fall

Immediate surgical evacuation via craniotomy is indicated for symptomatic subdural hematomas with thickness >10mm or midline shift >5mm, particularly in patients with neurological deterioration or decreased consciousness. 1, 2

Initial Assessment and Triage

Perform urgent non-contrast CT imaging to characterize hematoma size, location, and mass effect 1, 2. The critical measurements are:

• Maximal hematoma thickness (surgical threshold: >5-10mm)
• Degree of midline shift (surgical threshold: >5mm)
• Hematoma volume (>30 cm³ suggests need for intervention) 3

Assess neurological status using:

• Glasgow Coma Scale (GCS) - scores ≤13 typically require intervention 1, 2
• Pupillary examination - abnormal pupils indicate herniation risk 4
• Focal neurological deficits - progressive deficits mandate surgery 1

Critical pitfall: Elderly patients on anticoagulants can deteriorate rapidly even with small hematomas; do not be falsely reassured by initial stability 2.

Surgical Indications (Immediate Intervention Required)

Proceed urgently to surgery when ANY of the following are present:

• Hematoma thickness >10mm OR midline shift >5mm 1, 2
• GCS <15 with large volume hematoma (>30 cm³) 3
• Progressive neurological deterioration regardless of hematoma size 1
• Decreased level of consciousness attributable to the hematoma 1
• Significant mass effect with clinical symptoms 1, 2

Surgical approach: Craniotomy with subdural drain placement is preferred for acute subdural hematomas to reduce recurrence rates 1, 2. Burr hole drainage is reserved for chronic subdural hematomas 1.

Timing consideration: While earlier surgery shows trends toward better outcomes, the extent of underlying brain injury is more critical than absolute surgical timing 5. However, do not delay surgery when neurological deterioration occurs - this leads to significantly poorer outcomes 1.

Delayed Surgical Approach (Select Patients)

For older patients (typically >60 years) with GCS ≥13, stable neurological exam, and hematomas meeting surgical size criteria, close neuromonitoring with delayed intervention (6-31 days) is a safe alternative 6. This approach:

• Allows the acute hematoma to become chronic/subacute
• Permits smaller surgical incisions and burr hole drainage instead of craniotomy
• Achieved 68% good functional outcomes (GOS 4-5) at 3 months 6

Requirements for delayed approach:

• Monitorable neurological exam without progression 6
• Close serial neurological assessments 1, 2
• Serial CT imaging to monitor for expansion 1
• Immediate surgical availability if deterioration occurs 6

This approach is contraindicated if any neurological deterioration develops 1.

Conservative Management (Non-Surgical)

Conservative management with close monitoring is appropriate for:

• Small hematomas (<5mm thickness) with minimal mass effect 1, 2
• No midline shift or <5mm shift 2
• Stable patients without significant neurological deficits 1
• Asymptomatic or minimally symptomatic patients 1

Monitoring protocol:

• Regular neurological assessments (GCS, pupils, focal deficits) 2
• Serial CT imaging to detect progression 1
• Maintain euvolemia - avoid both hypovolemia and hypervolemia 1, 2

Important finding: No patient with initial subdural hematoma ≤3mm required surgery, although 11% enlarged to maximum 10mm 7. This supports conservative management for very small hematomas.

Anticoagulation Management

Rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K for patients on warfarin who develop subdural hematoma 1.

For patients on anticoagulation with negative initial CT:

• Delayed intracranial hemorrhage after negative CT is very rare (0.6% for warfarin patients) 4
• 24-hour observation with repeat CT at 20-24 hours is recommended by European guidelines, though evidence shows only 1.4-2% develop delayed hemorrhage 4
• Most delayed hemorrhages do not require neurosurgical intervention 4

Anticoagulation interruption: Typically hold for 7-15 days post-subdural hematoma, with low risk of ischemic events during this period 1. For traumatic subdural hematomas, restart anticoagulation approximately 4 weeks after surgical removal if no ongoing fall risk or alcohol abuse is present 4.

Predictors of Hematoma Expansion

Monitor closely for expansion if these risk factors are present:

• Larger initial hematoma size (>8.5mm predicts need for surgery with 81% accuracy) 7
• Concurrent subarachnoid hemorrhage 7
• Hypertension 7
• Convexity location 7
• Initial midline shift present 7
• Anticoagulant or antiplatelet use 2

Approximately 25% of acute subdural hematomas enlarge on follow-up imaging 7.

Post-Operative Management

After surgical evacuation:

• Admit to critical care for monitoring 3
• Maintain euvolemia and avoid hypovolemia to optimize cerebral perfusion 2
• Monitor for complications: seizures, infection, hematoma re-expansion 2
• Consider subdural drain placement during surgery to reduce recurrence 1, 2
• Secure airway with intubation if GCS deteriorates 2

Seizure prophylaxis: Antiepileptic drugs are NOT recommended for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes 4. Consider only if specific risk factors present (chronic subdural hematoma, prior epilepsy) 4.

Minimally Invasive Alternative

For patients with acute subdural hematoma who have GCS ≥13, hematoma thickness ≥7mm, moderate deficits without progression, and no need for immediate evacuation, twist-drill craniostomy with pressure-controlled fibrinolytic irrigation (TDC-FIT) achieved 90% near-complete resolution and 90% independence at 3 months, compared to 56.7% with open craniotomy 8. This represents an emerging alternative to traditional craniotomy in carefully selected patients.