What is the treatment for a subdural hematoma?

Treatment of Subdural Hematoma

Immediate surgical evacuation is indicated for symptomatic subdural hematoma with significant mass effect, neurological deterioration, or decreased level of consciousness, while stable patients with small or asymptomatic hematomas should be managed conservatively with close monitoring. 1

Initial Assessment and Surgical Triage

The decision between surgical and conservative management hinges on three key factors 1:

• Neurological status: Document Glasgow Coma Scale (GCS) score, pupillary examination (abnormal pupils indicate herniation risk), and focal neurological deficits 1
• Hematoma characteristics on CT: Measure maximal thickness and degree of midline shift 1
• Clinical stability: Assess for headache, altered consciousness, vomiting, and progressive symptoms 1

Surgical Management

Acute Subdural Hematoma

For acute subdural hematomas requiring surgery, proceed directly to surgical evacuation when neurological deterioration occurs, as delays lead to poorer outcomes. 1

• Traditional open craniotomy remains the standard approach for patients requiring immediate evacuation 1
• For patients with GCS ≥13, hematoma thickness ≥7 mm, moderate deficits without progression, and no need for immediate evacuation, twist-drill craniostomy with pressure-controlled fibrinolytic irrigation achieved 90% independence at 3 months compared to 56.7% with craniotomy 2
• The extent of underlying brain injury and ability to control intracranial pressure are more critical to outcome than absolute timing of surgery, though earlier intervention shows favorable trends 3

Chronic Subdural Hematoma

Burr hole drainage with subdural drain placement is the preferred first-line surgical approach for chronic subdural hematomas to reduce recurrence rates. 1

• Recurrence occurs in 2-37% of cases after initial evacuation 4
• For refractory or recurrent hematomas with thick membranes, subdural-peritoneal shunt placement provides reliable treatment with rapid neurological improvement and no recurrence 5, 4

Conservative Management

Conservative management is appropriate for stable patients without significant neurological deficits, particularly for small or asymptomatic hematomas. 1

This requires 1:

• Regular neurological assessments with serial imaging to monitor for progression
• Maintaining euvolemia (avoiding hypervolemia, which does not improve outcomes and may cause complications)
• Immediate conversion to surgical management if neurological deterioration occurs

Anticoagulation Management

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

• Interrupt anticoagulation for 7-15 days, which carries low risk of ischemic events during this period 1
• For patients on anticoagulation with negative initial CT after trauma, delayed intracranial hemorrhage is very rare (0.6% for warfarin patients); observe for 24 hours with repeat CT at 20-24 hours 1
• Restart anticoagulation approximately 4 weeks after surgical removal of traumatic subdural hematoma if no ongoing fall risk or alcohol abuse is present 1

Post-Operative Management

Do NOT use antiepileptic drugs for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes. 1

• Consider antiepileptic drugs only if specific risk factors are present, such as chronic subdural hematoma or prior epilepsy 1

Nonsurgical Adjuncts

While surgical intervention remains first-line treatment, certain adjuncts may be considered 6:

• Dexamethasone should be used with caution for selected patients given its side effects 6
• Tranexamic acid may be utilized as adjunct therapy to surgery, though more randomized trials are needed 6
• Middle meningeal artery embolization shows interesting results but carries risks including intracerebral hemorrhage, stroke, and vasospasm that require further study 6

Special Populations

Pediatric Patients

The same surgical indications apply, but additional considerations include 7:

• Mandatory funduscopic examination to check for retinal and preretinal hemorrhages characteristic of infantile subdural hematoma 7
• Consider child abuse evaluation including skeletal survey, brain MRI, and cervical spine MRI 7

Subdural Hematoma with Spontaneous Intracranial Hypotension

Perform MRI of brain with contrast and whole spine to investigate for spinal CSF leak 1