What is the management of a subdural hematoma with active brain bleeding?

Management of Subdural Hematoma with Active Brain Bleeding

Immediate Surgical Intervention

Immediate surgical evacuation is indicated for subdural hematoma with active bleeding when there is significant mass effect, neurological deterioration, or decreased level of consciousness. 1

Surgical Indications and Timing

• Operate emergently if the patient demonstrates:

  • Altered or decreased consciousness 1, 2
  • New or worsening focal neurological deficits 2
  • Abnormal pupils indicating herniation risk 1
  • Significant midline shift or mass effect on imaging 1

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

• For acute subdural hematoma with active bleeding, do not delay surgical intervention when neurological deterioration occurs, as delay leads to poorer outcomes 1

• The timing of surgery (within hours) is less critical than controlling intracranial pressure postoperatively; the extent of underlying brain injury dictates outcome more than the subdural clot itself 3

Reversal of Coagulopathy

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

• Maintain platelet count above 50×10⁹/L in patients with ongoing bleeding and/or traumatic brain injury 4

• Administer platelets to achieve this threshold in the setting of active intracranial hemorrhage 4

Blood Pressure Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure 80-110 mmHg 2

• If ICP monitoring is in place, ensure cerebral perfusion pressure 60-70 mmHg 2

• Aggressive blood pressure control is critical but must balance cerebral perfusion needs 4

Intracranial Pressure Monitoring

• ICP monitoring is indicated when:

  • Neurological surveillance is not feasible 2
  • Hemodynamic instability is present 2
  • Compressed basal cisterns or other severity signs exist on imaging 2
  • Glasgow Coma Scale score is 3-7 3

• Postoperative ICP control is more critical to outcome than absolute timing of subdural blood removal 3

• Target postoperative **ICP <45 mmHg**, as ICP >45 mmHg correlates with worse outcomes 3

Conservative Management Contraindications

Conservative management is NOT appropriate for subdural hematoma with active bleeding and neurological symptoms. 1, 2

• Conservative management with close monitoring is reserved only for:
  • Small, asymptomatic hematomas 1, 2
  • Stable patients without significant neurological deficits 1
  • No evidence of mass effect or midline shift 2

Temperature Management

• Employ early measures to reduce heat loss and warm hypothermic patients to achieve normothermia 4

• Hypothermia at 33-35°C for 48 hours may be applied in patients with traumatic brain injury only after bleeding from other sources has been controlled 4

Critical Pitfalls

• Never delay surgery when active bleeding is present with neurological deterioration 1

• Avoid hypervolemia, as it does not improve outcomes and may cause complications; instead maintain euvolemia 1, 2

• The risk of significant expansion of acute subdural hematoma requiring rescue craniotomy ranges from 6-22% within 12-24 hours 4

• Approximately half of patients with traumatic cerebral contusions experience hemorrhagic progression, typically within the first 12 hours but potentially as late as 3-4 days after injury 4