Management of 5mm Subdural Hematoma
A 5mm subdural hematoma should be managed conservatively with close neurological monitoring, as it falls below the surgical threshold of 10mm thickness and 5mm midline shift. 1, 2
Initial Assessment
Obtain immediate CT scan to confirm the SDH size, assess for mass effect, midline shift, and evaluate cisternal compression 1. A 5mm SDH without significant mass effect or midline shift >5mm does not meet surgical criteria 2.
Assess neurological status using Glasgow Coma Scale, pupillary examination, and focal neurological deficits 3, 4. Document any changes from baseline, as deterioration by 2 or more GCS points may alter management even with small hematomas 2.
Laboratory evaluation must include PT, PTT, INR, and platelet count to identify coagulopathy requiring reversal 5.
Conservative Management Strategy
Maintain close neurological monitoring with serial examinations at least every 4 hours initially 3. This is the cornerstone of management for small, asymptomatic SDH 1.
Optimize cerebral perfusion by:
- Maintaining systolic blood pressure >100 mmHg or mean arterial pressure 80-110 mmHg 3, 4
- Ensuring cerebral perfusion pressure 60-70 mmHg if ICP monitoring is in place 6
- Maintaining PaO2 >60 mmHg 4
- Avoiding hypovolemia and maintaining euvolemia 1, 4
Manage anticoagulation/antiplatelet therapy by reversing these agents until hemorrhage is stabilized on imaging 4, 5. This prevents hematoma expansion, which is a critical concern in the acute phase 5.
Consider seizure prophylaxis as part of initial management, though this should be individualized based on risk factors 4, 5.
Indications for Surgical Intervention
Immediate surgical evacuation is indicated if:
- Altered consciousness develops 1
- New or worsening focal neurological deficits appear 1
- GCS decreases by 2 or more points 2
- Asymmetric or fixed dilated pupils develop 2
- ICP exceeds 20 mmHg (if monitoring in place) 2
Note the critical surgical thresholds: SDH thickness ≥10mm OR midline shift ≥5mm warrant surgical evacuation regardless of GCS score 2. Your 5mm SDH is below this threshold.
ICP Monitoring Considerations
ICP monitoring is NOT routinely indicated for a 5mm SDH with normal neurological exam and no mass effect 6. However, consider ICP monitoring if:
- Neurological surveillance is not feasible 6
- Hemodynamic instability is present 6
- Compressed basal cisterns or other severity signs exist on imaging 6
The BEST-TRIP trial showed no difference in neurological outcome between ICP monitoring and clinical surveillance with repeated CT scans, supporting conservative monitoring in appropriate cases 6.
Follow-up Protocol
Repeat CT imaging at 4-6 weeks to ensure resolution or stability of the hematoma 1. Earlier repeat imaging should be obtained if any neurological deterioration occurs.
Close outpatient follow-up is essential for patients discharged with conservative management 1.
Patient education regarding warning signs requiring immediate medical attention is crucial, including worsening headache, confusion, weakness, or seizures 1.
Common Pitfalls
Avoid premature discharge without establishing reliable neurological monitoring capability. Even small SDH can expand or cause delayed deterioration 4, 5.
Do not ignore anticoagulation status. Failure to reverse anticoagulation or antiplatelet therapy can lead to hematoma expansion, converting a manageable 5mm SDH into a surgical emergency 5.
Maintain normothermia, eucarbia, and euglycemia as deviations from these parameters can worsen secondary brain injury 4.