What is the treatment for a holohemispheric subdural hematoma?

Treatment of Holohemispheric Subdural Hematoma

Immediate surgical evacuation via craniotomy is indicated for holohemispheric subdural hematomas with thickness >5mm and midline shift >5mm, particularly when accompanied by neurological deterioration or mass effect. 1, 2

Surgical Indications

The decision for surgical intervention depends on specific radiographic and clinical criteria:

• Hematoma thickness >5mm with midline shift >5mm constitutes a clear indication for craniotomy 1, 2
• Progressive neurological deterioration mandates urgent surgical evacuation regardless of hematoma size 3, 4
• Decreased level of consciousness requires surgical intervention 3
• Signs of brainstem compression or impending herniation necessitate emergency surgery 5, 6

For stable patients without significant neurological deficits and hematomas <5mm thickness with <5mm midline shift, conservative management with close neurological monitoring may be appropriate 3, 4.

Surgical Technique

Large fronto-parieto-temporal craniotomy is the preferred approach for holohemispheric subdural hematomas:

• Craniotomy should have a diameter of at least 12cm, extending to the midline 7
• The craniotomy must adequately cover the entire hematoma extent 8
• Durotomy with enlargement duroplasty should be performed 7
• Exposure of the floor of the middle cranial fossa is important to identify potential bleeding sources 8
• Be prepared to convert to decompressive craniectomy if significant brain swelling is encountered during evacuation 8

Alternative Approaches in Select Cases

For hyperacute subdural hematomas (within first few hours) with mixed-density components on CT suggesting uncoagulated blood, temporizing subdural evacuating port system (SEPS) placement may be considered as a bridge to definitive craniotomy 6. However, this is not a substitute for definitive surgical treatment and should only be used to rapidly reduce intracranial pressure while preparing for craniotomy 6.

Critical Pitfalls to Avoid

• Do not attempt burr hole drainage alone for acute holohemispheric subdural hematomas, as coagulated blood cannot be adequately evacuated through small openings 8, 6
• Avoid delaying surgery in patients with neurological deterioration, as this leads to significantly worse outcomes 3
• Pay careful attention to dural sinus and bridging vein injuries during evacuation 8
• Do not remove ischemic brain tissue if present; focus only on hematoma evacuation 7

Perioperative Management

Preoperative Considerations

• Correct coagulation disorders before surgery in collaboration with hematology if time permits 7
• If the patient received antiplatelet agents, consider preoperative platelet transfusion 7
• Fibrinogen levels should be normalized, particularly if thrombolysis was administered 7

Postoperative ICU Management

• Place intracranial pressure monitor during surgery for postoperative monitoring 7
• Maintain cerebral perfusion pressure >60mmHg using volume replacement and/or vasopressors as needed 7
• Obtain control CT scan within 24 hours or earlier if signs of intracranial hypertension develop 7
• Initiate neurological assessments at least every 4 hours 3
• Begin thromboembolic prophylaxis with subcutaneous heparin from postoperative day 2 after neurosurgical consultation 7
• Use appropriate sedation (such as dexmedetomidine) for agitation control 1
• Manage blood pressure carefully to maintain adequate cerebral perfusion while avoiding hypertension 1

Special Populations

For interhemispheric subdural hematomas (a specific subtype that may extend holohemispherically), parasagittal craniotomy is the optimal surgical approach 9. These cases frequently occur in patients with coagulation disorders and require particular attention to correcting underlying coagulopathy 4, 9.

In elderly patients (e.g., age >80 years), advanced age should not automatically preclude surgical intervention if clinical and radiographic criteria are met 3. The decision should be based on neurological status and mass effect rather than age alone 3.