Should a patient with a 3.5mm traumatic cerebellar subdural hematoma (SDH) be transferred to a tertiary care facility?

From the Guidelines

A traumatic cerebellar subdural hematoma (SDH) of 3.5mm should be transferred to a tertiary care facility due to the high risk of life-threatening complications. Even though the size may seem small, cerebellar SDHs carry significant risks due to the limited space in the posterior fossa and proximity to vital structures like the brainstem, as highlighted in the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage 1. These hematomas can rapidly expand and cause life-threatening complications including brainstem compression, obstructive hydrocephalus, and increased intracranial pressure. During transfer, the patient should be stabilized with:

• Appropriate airway management
• Blood pressure control (maintaining systolic BP between 120-140 mmHg to prevent hematoma expansion while ensuring adequate cerebral perfusion)
• Neurological monitoring with frequent assessments of Glasgow Coma Scale, pupillary responses, and vital signs. If deterioration occurs, hyperventilation and osmotic agents like mannitol (1g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) may be needed temporarily. The tertiary center offers neurosurgical expertise for potential surgical intervention, advanced neuromonitoring capabilities, and specialized neurointensive care that may not be available at smaller facilities, significantly improving patient outcomes in these potentially dangerous situations, as supported by the most recent guideline from the American Heart Association/American Stroke Association 1.

From the Research

Traumatic Cerebellar SDH Management

• The decision to transfer a patient with a traumatic cerebellar subdural hematoma (SDH) to a tertiary care facility depends on various factors, including the size and location of the hematoma, the patient's clinical condition, and the availability of resources at the current facility.
• A study published in 2016 2 found that patients with small isolated traumatic SDH (<10 cm(3) blood volume) spent less time in the ICU, demonstrated neurologic and medical stability during hospitalization, and did not require any neurosurgical intervention.
• However, the same study noted that patients with small tSDH and additional intracranial hemorrhages may still benefit from ICU observation due to low rates of medical decline (4%) and neurologic decline (4%).
• Another study published in 2001 3 focused on the management of spontaneous cerebellar hematomas and found that the degree of fourth ventricular compression was significantly correlated with the volume of the hematoma, hydrocephalus, and the preoperative Glasgow Coma Scale (GCS) score.
• The study suggested that patients with Grade III fourth ventricular compression should undergo urgent clot evacuation before deterioration, while those with Grade I or II compression may not require surgical intervention if the fourth ventricle is not totally obliterated at the level of the clot.
• A more recent study published in 2021 4 discussed the surgical management of post-traumatic intracranial hematomas, including acute subdural hematoma, and highlighted the importance of operative techniques, additional options, and potential pitfalls of surgical intervention.
• The study recommended a wide craniotomy covering the hematoma for evacuation, control of bleeding, and prevention of blood reaccumulation, and emphasized the need to pay attention to injuries of dural sinuses and bridging veins.
• Other studies have reported on the spontaneous resolution of acute cranial subdural hematomas 5 and the treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt 6.
• These studies suggest that the management of traumatic cerebellar SDH should be individualized based on the patient's specific condition and the availability of resources, and that transfer to a tertiary care facility may be necessary in certain cases to ensure optimal care.

Considerations for Transfer

• The size of the hematoma (3.5mm in this case) is relatively small, but the location in the cerebellum may require closer monitoring and potentially more aggressive management due to the risk of brainstem compression and hydrocephalus.
• The patient's clinical condition, including their GCS score, vital signs, and presence of any neurological deficits, should be carefully evaluated to determine the need for transfer to a tertiary care facility.
• The availability of resources, including neurosurgical expertise, ICU capacity, and advanced imaging capabilities, should also be considered when deciding whether to transfer the patient.