What is the management plan for a patient with acute subdural hematoma (SDH) and midline shift, Glasgow Coma Scale (GCS) score of 4-5, sluggish pupillary reflex, and impaired renal function due to chronic kidney disease (CKD) requiring hemodialysis (HD) initiation?

Management of Acute Subdural Hematoma with Severe Neurological Compromise in a Hemodialysis Patient

This patient requires immediate surgical evacuation of the subdural hematoma via craniotomy, with temporary transition to peritoneal dialysis postoperatively to avoid anticoagulation-related rebleeding. 1, 2, 3

Immediate Surgical Intervention is Mandatory

Surgical evacuation must be performed emergently because this patient meets absolute criteria for operative intervention: acute SDH with midline shift, GCS 4-5 (comatose), and sluggish pupillary reflexes indicating impending herniation. 2

• Any acute SDH with midline shift >5mm requires surgical evacuation regardless of GCS score, and this patient has both significant midline shift AND profound neurological compromise. 2
• The presence of sluggish pupillary reflexes in a comatose patient (GCS <9) with acute SDH is an absolute indication for immediate craniotomy, as this represents evolving transtentorial herniation. 1, 4, 2
• Craniotomy with or without bone flap removal (decompressive craniectomy) is the required surgical approach—burr hole drainage is inadequate for acute SDH. 2

Airway Management Before Surgery

• Immediate endotracheal intubation is mandatory because GCS 4-5 is far below the threshold of GCS ≤8 that requires airway protection. 1
• Intubation prevents aspiration and allows controlled ventilation during transport to the operating room and throughout the perioperative period. 1

Intraoperative and Postoperative Physiological Targets

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion pressure, particularly critical given the combination of intracranial hypertension and potential hemodynamic instability from uremia. 1, 4
• Target cerebral perfusion pressure of 60-70 mmHg postoperatively; avoid exceeding 70 mmHg as this increases risk of acute respiratory distress syndrome. 4
• Maintain oxygen saturation >95% to prevent hypoxemic secondary brain injury. 1
• Place an ICP monitor intraoperatively or immediately postoperatively, as preoperative anisocoria (sluggish pupils) is a specific criterion mandating ICP monitoring after hematoma evacuation. 4, 2

Critical Dialysis Management Strategy

Immediately transition from hemodialysis to peritoneal dialysis postoperatively to avoid the catastrophic risk of rebleeding from heparin anticoagulation required during hemodialysis. 3

• Hemodialysis patients with subdural hematoma have exceptionally high mortality (45.9% at 1 year), with mortality reaching 81% in those requiring anticoagulation. 5
• Peritoneal dialysis allows continuation of renal replacement therapy without systemic anticoagulation, dramatically reducing rebleeding risk. 3
• Continue peritoneal dialysis for a minimum of 6-8 weeks postoperatively before considering cautious resumption of hemodialysis without anticoagulation. 3
• If peritoneal dialysis is not immediately available, use continuous renal replacement therapy (CRRT) with regional citrate anticoagulation rather than heparin, as CRRT is more physiologically appropriate in hemodynamically unstable patients and citrate avoids systemic anticoagulation. 6

Renal Replacement Therapy Technical Considerations

• Do not delay surgery to initiate dialysis unless the patient has life-threatening hyperkalemia (>7.0 mEq/L with ECG changes) or severe metabolic acidosis (pH <7.0) causing hemodynamic instability. 6
• If emergent dialysis is required preoperatively, use CRRT with citrate anticoagulation rather than intermittent hemodialysis, as intermittent hemodialysis causes greater intracranial pressure fluctuations that could precipitate herniation. 6
• Place a peritoneal dialysis catheter in the operating room at the time of craniotomy if feasible, or immediately postoperatively. 3

Prognosis and Family Communication

Despite surgical intervention, this patient faces extremely poor prognosis given the combination of GCS 4-5 and sluggish pupils. 7

• Mortality in acute SDH patients with GCS 3 is 80.7%, with 57.1% of survivors remaining in a vegetative state. 7
• Bilaterally sluggish or unreactive pupils carry 85.9% mortality, compared to 44.4% with reactive pupils. 7
• However, surgical treatment reduces mortality from 91.0% (conservative management) to 64.3%, making surgery the only option that provides any meaningful survival chance. 7
• Avoid making irreversible treatment limitation decisions before 72 hours unless brain death criteria are met, as neurological status at 72 hours is a better prognostic indicator than initial presentation. 8

Critical Pitfalls to Avoid

• Do not delay surgery to optimize dialysis status, correct uremia, or await family discussions—every minute of delay with impending herniation worsens outcome. 1, 2
• Do not resume hemodialysis with heparin anticoagulation in the early postoperative period (minimum 6-8 weeks), as this causes catastrophic rebleeding with mortality approaching 81%. 5, 3
• Do not use intermittent hemodialysis if dialysis is required perioperatively—use CRRT with citrate or transition to peritoneal dialysis to avoid intracranial pressure fluctuations. 6
• Do not administer long-acting sedatives or paralytics postoperatively before establishing ICP monitoring, as this masks neurological deterioration. 8