What is the management for a patient with spontaneous subdural hematoma (SDH)?

Management of Spontaneous Subdural Hematoma

For spontaneous subdural hematoma, conservative management with close neurological monitoring is recommended for stable patients without significant neurological deficits, while surgical intervention (burr hole drainage as first-line) should be performed emergently for patients with neurological deterioration, decreased consciousness, or significant mass effect. 1

Initial Assessment and Diagnostic Workup

Neuroimaging

• CT scan is the gold standard for initial diagnosis of acute subdural hematoma, with sensitivity equivalent to MRI gradient echo sequences for detecting acute blood 2
• Perform CT angiography to identify patients at risk for hematoma expansion and to evaluate for underlying vascular malformations, tumors, or other structural lesions 2
• Consider MRI with contrast if subdural hygroma or spontaneous intracranial hypotension is suspected as an underlying cause 3

Clinical Evaluation

• Assess Glasgow Coma Scale (GCS), pupillary examination, and detailed neurological examination to establish baseline 1
• Evaluate for headache, altered consciousness, vomiting, and focal neurological deficits 1
• Obtain complete blood count, coagulation studies (PT/INR, aPTT), electrolytes, renal function, and glucose 2
• Screen for anticoagulant and antiplatelet medications, as warfarin-related hemorrhages have increased morbidity and mortality 2

Conservative Management Protocol

Patient Selection

• Conservative management is appropriate for conscious patients with small subdural hematomas (<10mm thickness), no mass effect on CT, and no neurological deterioration 4
• Spontaneous resolution occurs in approximately 74% of appropriately selected conscious patients (17 of 23 in one series) 4
• Patients with hematoma thickness >10mm or volume >53ml have higher likelihood of requiring surgical intervention 4

Monitoring Requirements

• Perform neurological examinations at minimum every 4 hours initially, assessing GCS, pupillary response, motor strength, and sensory function 5
• Serial CT imaging to monitor for hematoma expansion or development of mass effect 1, 4
• Maintain euvolemia to optimize cerebral perfusion 1

Coagulation Reversal

• Reverse anticoagulation immediately if present, targeting platelet count >100 × 10⁹/L and INR <1.4 in warfarin-treated patients 5
• Consider thromboprophylaxis only after hemostasis is secured and hematoma stability confirmed on serial imaging 5

Surgical Indications and Techniques

Absolute Indications for Surgery

Surgery is mandated for any of the following:

• Neurological deterioration of any degree 1, 5
• Decreased level of consciousness 1, 5
• Development or worsening of focal neurological deficits 1, 5
• Increased intracranial pressure refractory to medical management 1, 5
• Progressive increase in hematoma size on serial CT 5
• Increasing mass effect or midline shift 5

Surgical Approach

• Burr hole drainage is the preferred first-line surgical treatment for symptomatic chronic or subacute subdural hematomas 1
• Craniotomy should be reserved for acute-on-chronic subdural hematomas with solid components that cannot be adequately drained through burr holes 1
• Consider placement of subdural drain during surgery to reduce recurrence rates 1
• For cerebellar hemorrhage with deterioration or brainstem compression, surgical removal should be performed as soon as possible 2

Care Setting and Transfer Criteria

Hospital Level of Care

• Provision of care at centers with full range of high-acuity care and neurosurgical expertise is recommended to improve outcomes 2
• For patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial location, neuro-specific ICU care is reasonable compared to general ICU 2
• Transfer to centers with neurosurgical capabilities is recommended for patients with clinical hydrocephalus requiring definitive management 2

Multidisciplinary Care

• Care delivery should include multidisciplinary teams trained in neurological assessment 2
• Initiate appropriate life-sustaining therapies before transportation for patients without adequate airway protection or stable hemodynamic profile 2

Blood Pressure Management

Target Parameters

For patients with spontaneous intracranial hemorrhage (applicable principles):

• If SBP >200 mmHg or MAP >150 mmHg: aggressive reduction with continuous IV infusion, monitoring BP every 5 minutes 2
• If SBP >180 mmHg or MAP >130 mmHg with possible elevated ICP: monitor ICP and reduce BP while maintaining cerebral perfusion pressure ≥60 mmHg 2
• If SBP >180 mmHg or MAP >130 mmHg without elevated ICP: modest reduction to MAP 110 mmHg or target BP 160/90 mmHg with clinical reexamination every 15 minutes 2

Special Considerations

Age-Related Factors

• Advanced age is an important factor in decision-making but should not automatically preclude surgical intervention if needed 1
• Cerebral atrophy (present in over half of patients in one series) may influence natural history and management 4

Spinal Subdural Hematoma

• Emergent surgical intervention is indicated for patients with severe neurological deficits (paraplegia, quadriplegia), as presence of severe deficits predicts poor neurological outcome 6
• Conservative management should be considered for patients with mild neurological deficits, as spontaneous resolution with favorable outcomes is often observed 6
• Be aware that spinal SDH can occur concomitantly with intracranial SDH, requiring imaging of both brain and spine 7

Critical Pitfalls to Avoid

• Delaying surgical intervention when neurological deterioration occurs leads to significantly worse outcomes 5
• Do not assume all acute subdural hematomas require immediate surgery; appropriately selected conscious patients with small hematomas can be managed conservatively 4
• Avoid hypervolemia, as it does not improve outcomes and may lead to complications 1
• Do not miss underlying CSF leak or spontaneous intracranial hypotension as etiology, particularly in subdural hygromas 3
• Six of 23 conservatively managed patients (26%) eventually required burr hole drainage at mean 15 days post-injury, emphasizing need for vigilant monitoring 4