What are the recommendations for conservative management of subdural hematoma (SDH)?

Conservative Management of Subdural Hematoma

Initial Assessment and Diagnostic Imaging

Conservative management is appropriate for small, asymptomatic subdural hematomas without significant mass effect, requiring close neurological monitoring and serial imaging rather than immediate surgical intervention. 1, 2

• Obtain non-contrast CT scan immediately to assess hematoma size, location, midline shift, and mass effect 1, 3
• Document Glasgow Coma Scale (GCS) score, pupillary examination, and focal neurological deficits 3
• Evaluate for signs of increased intracranial pressure including compression of basal cisterns, ventricular effacement, or midline shift >5mm 1

Criteria for Conservative Management

Patients meeting ALL of the following criteria can be managed conservatively:

• GCS score of 15 with midline shift <10mm 4
• **GCS score <15 with midline shift <5mm** (shifts >5mm predict neurological deterioration within 3 days) 4
• Absence of altered consciousness 1
• No new or worsening focal neurological deficits 1
• Asymptomatic or stable symptoms 1, 2

Research demonstrates that hematoma volume and degree of midline shift on initial CT are the strongest independent predictors of delayed surgical intervention 5. Patients with larger initial SDH volumes and accompanying midline shift require particularly careful monitoring for hematoma progression 5.

Monitoring Protocol

Serial neurological examinations at least every 4 hours initially are the cornerstone of conservative management 1

Hemodynamic Management:

• Maintain cerebral perfusion pressure 60-70 mmHg if ICP monitoring is in place 1, 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure 80-110 mmHg 1
• Maintain euvolemia to optimize cerebral perfusion 1

ICP Monitoring Considerations:

• NOT routinely indicated for small SDH with normal neurological exam and no mass effect 1
• Consider ICP monitoring if: neurological surveillance is not feasible, hemodynamic instability is present, or compressed basal cisterns exist on imaging 1

Follow-Up Imaging Strategy

• Repeat CT scan if new or worsened symptoms develop to assess for hematoma enlargement or new hemorrhage 6, 1
• Consider repeat imaging at 4-6 weeks to ensure resolution or stability 1
• Daily CT scans may be warranted in the first 3-4 days for patients with GCS <15 or midline shift approaching 5mm 4
• Total hospital stay of 6-7 days may suffice for patients who become fully conscious, with close follow-up during the first 3-4 weeks 4

Special Populations

Parafalcine SDH:

Parafalcine subdural hematomas represent a distinct, clinically benign entity with significantly lower incidence of radiographic progression, neurologic deterioration, or need for neurosurgical intervention compared to convexity SDH 7. These patients do not benefit from ICU admission and can be managed on the floor with shorter length of stay 7.

Pediatric Patients:

• Perform funduscopic examination to check for retinal and preretinal hemorrhages 3
• Consider child abuse evaluation including skeletal survey and MRI 3
• Same conservative management principles apply for stable patients without significant neurological deficits 3

Indications for Urgent Surgical Intervention

Immediate surgical evacuation is required for:

• Development of altered consciousness 1
• New or worsening focal neurological deficits 1
• Neurological deterioration with declining GCS score 5, 4
• Significant mass effect with impending herniation 3
• Increased intracranial pressure refractory to medical management 3

Critical pitfall: Delaying surgical intervention when neurological deterioration occurs leads to poorer outcomes 3. Approximately 35% of initially nonoperative acute SDH patients may require delayed evacuation, typically within 17 days 5.

Medical Management During Conservative Treatment

• Position patient with head elevated as comfortable 2
• For intracranial hypertension: administer mannitol 20% or hypertonic saline solution at 250 mOsm over 15-20 minutes 2
• Consider thromboprophylaxis during immobilization 2
• Manage anticoagulant/antiplatelet therapy with special consideration 1

Patient Education and Discharge Planning

Advise patients to seek urgent medical attention for:

• New-onset severe headache 2
• Neurological deficits 2
• Altered mental status 2

Close outpatient follow-up is mandatory for all patients discharged with conservative management 1.