From the Guidelines
Non-surgical management is a viable option for select patients with acute on chronic subdural hematomas, particularly those with small hematomas, minimal symptoms, and no significant midline shift, as evidenced by recent studies 1. The primary consideration in managing acute on chronic subdural hematomas is the patient's overall clinical condition, including the size of the hematoma, the presence of midline shift, and the patient's neurological status.
- Key factors that influence the decision for non-surgical management include:
- Hematoma size: Typically less than 10mm in thickness
- Midline shift: Minimal or no shift
- Neurological status: Patients who are neurologically intact or have only mild deficits
- Symptoms: Minimal symptoms
- The non-surgical approach involves:
- Close neurological monitoring
- Serial imaging, typically CT scans every 4-6 weeks until resolution
- Medical management, which may include:
- Corticosteroids, such as dexamethasone, to reduce inflammation and edema
- Tranexamic acid to prevent further bleeding by inhibiting fibrinolysis
- Discontinuation of anticoagulants and antiplatelet medications if possible
- Adequate hydration to maintain cerebral perfusion
- Seizure prophylaxis with levetiracetam in patients with seizures
- A recent study published in The Lancet Neurology in 2022 1 highlights the variability in surgical management of acute subdural hematomas across different centers, suggesting that non-surgical management may be a viable option for some patients.
- It is essential to note that patients undergoing non-surgical management must be closely monitored for neurological deterioration, which would necessitate immediate surgical intervention.
- The rationale for non-surgical management is based on the potential for some subdural hematomas to resolve spontaneously through natural reabsorption processes, especially when inflammation is controlled and further bleeding is prevented, as supported by the most recent and highest quality study available 1.
From the Research
Indications for Non-Surgical Management
- Acute on chronic subdural hematoma (acSDH) may be considered for non-surgical management in certain cases, as evidenced by studies on chronic subdural hematoma (CSH) treatment 2, 3, 4, 5.
- Non-surgical management options include steroid therapy, such as dexamethasone or low-dose hydrocortisone, which have shown promise in reducing hematoma volume and improving patient outcomes 2, 5.
- The decision to pursue non-surgical management should be based on individual patient factors, including symptom severity, hematoma size, and overall health status 4, 5.
Considerations for Acute on Chronic Subdural Hematoma
- AcSDH is associated with a high risk of acute symptomatic seizures (ASz) and status epilepticus, which can impact patient outcomes 6.
- Prophylactic treatment with antiepileptic drugs may be considered for patients with acSDH to reduce the risk of seizures and improve outcomes 6.
- Non-surgical management of acSDH may be feasible in certain cases, but close monitoring and follow-up are essential to ensure optimal patient care 6.
Evidence for Non-Surgical Management
- A retrospective study of 122 CSH patients found that dexamethasone treatment was effective in reducing hematoma volume and improving patient outcomes, with a favorable outcome rate of 96% 2.
- A case series of 18 patients with CSH treated with low-dose hydrocortisone found significant reductions in hematoma volume and improvement in patient outcomes, with no complications reported 5.
- A review of the literature on CSH management highlights the need for further study on non-surgical management options, including steroid therapy and other medical treatments 3, 4.