Treatment of Subdural Hematoma
The treatment of subdural hematoma depends critically on neurological status and hematoma characteristics: immediate surgical evacuation is required for symptomatic patients with significant mass effect or neurological deterioration, while stable patients with small or asymptomatic hematomas can be managed conservatively with close monitoring. 1
Initial Assessment and Risk Stratification
The first step is determining surgical urgency through systematic evaluation 1:
- Assess Glasgow Coma Scale (GCS) score - this is the most critical prognostic factor, with GCS 3-4 correlating strongly with poor outcome 1, 2
- Perform pupillary examination - abnormal pupils indicate herniation risk and require immediate intervention 1
- Document focal neurological deficits - progressive deficits mandate surgical evacuation 1
- Measure CT characteristics - maximal hematoma thickness and degree of midline shift determine management 1
A common pitfall is delaying intervention when neurological deterioration occurs, which leads to significantly poorer outcomes. 1
Surgical Management
Acute Subdural Hematoma
Immediate surgical evacuation is indicated for 1:
- Symptomatic subdural hematoma with significant mass effect
- Neurological deterioration or decreased level of consciousness
- Progressive symptoms despite conservative measures
The traditional approach is craniotomy for acute subdural hematoma 1. However, recent evidence suggests that for patients with GCS ≥13, hematoma thickness ≥7 mm, and no need for immediate evacuation, twist-drill craniostomy with pressure-controlled fibrinolytic irrigation (TDC-FIT) achieved 90% independence at 3 months compared to 56.7% with open craniotomy 3.
Important caveat: While older literature emphasized operating within 4 hours of injury, more recent data shows that the extent of underlying brain injury and ability to control intracranial pressure are more critical to outcome than absolute timing of clot removal 2. This means you should not rush to surgery in stable patients, but you must not delay when deterioration occurs.
Chronic Subdural Hematoma
Burr hole drainage is the preferred first-line surgical approach for chronic subdural hematomas 1:
- Place subdural drain to reduce recurrence rates 1
- Recurrence rates range from 2-37% after initial evacuation 4
- Middle meningeal artery embolization (MMAE) is emerging as an effective treatment for promoting resorption and reducing recurrence 5
Conservative Management
Conservative management with close monitoring is appropriate for stable patients without significant neurological deficits, particularly for small or asymptomatic hematomas 1:
- Perform regular neurological assessments to detect deterioration 1
- Maintain euvolemia (avoiding hypervolemia, which does not improve outcomes and may cause complications) 1
- Obtain serial imaging to monitor for progression 1
Anticoagulation Management
For patients on anticoagulation who develop subdural hematoma, rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K 1:
- The duration of anticoagulation interruption is typically 7-15 days, with low risk of ischemic events during this period 1
- Restart anticoagulation approximately 4 weeks after surgical removal if no ongoing fall risk or alcohol abuse is present 1
Medical Adjuncts
Mannitol is FDA-approved for reduction of intracranial pressure and treatment of cerebral edema 6, which can be used as a temporizing measure in patients with elevated ICP awaiting surgical intervention.
Antiepileptic drugs are NOT recommended for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes 1. Consider them only if specific risk factors are present, such as chronic subdural hematoma or prior epilepsy 1.
Special Populations
Pediatric Patients
The management principles are similar to adults 7:
- Immediate surgical evacuation for symptomatic hematoma with mass effect or neurological deterioration 7
- Conservative management for stable patients without significant deficits 7
- Critical consideration: Perform funduscopic examination to check for retinal and preretinal hemorrhages, which are characteristic of infantile subdural hematoma 7
- Mandatory evaluation for child abuse including skeletal survey and MRI of brain and cervical spine 7
Important pediatric-specific finding: Infantile acute subdural hematoma, if treated conservatively or neglected, commonly progresses to chronic subdural hematoma (occurring in 85% of conservatively managed cases at mean 28 days) 8. Early recognition and suitable treatment may prevent this progression 8.
Subdural Hematoma with Spontaneous Intracranial Hypotension
Perform MRI of brain with contrast and whole spine to investigate for spinal CSF leak when subdural hematoma occurs in the context of spontaneous intracranial hypotension 1.
Post-Operative Monitoring
For patients on anticoagulation with negative initial CT after fall, delayed intracranial hemorrhage is very rare (0.6% for warfarin patients), and 24-hour observation with repeat CT at 20-24 hours is recommended 1.