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

Management of Subdural Hematoma

For acute subdural hematoma (SDH) with significant mass effect (thickness >5mm, midline shift >5mm) or neurological deterioration, immediate surgical evacuation via craniotomy is recommended, while chronic SDH should be treated with burr hole drainage as first-line, and stable asymptomatic cases can be managed conservatively with close monitoring. 1, 2

Acute Subdural Hematoma Management

Immediate Surgical Indications

• Remove acute SDH urgently if thickness >5mm with midline shift >5mm 1
• Operate immediately for any patient with neurological deterioration regardless of hematoma size 1, 2
• Craniotomy is the preferred surgical approach for acute SDH (as opposed to burr holes which are reserved for chronic cases) 2

Pre-operative Stabilization

• Reverse anticoagulation immediately in patients with elevated INR using prothrombin complex concentrate (preferred over fresh frozen plasma) plus vitamin K 1
• Control blood pressure with titratable agents to balance rebleeding risk against maintaining cerebral perfusion 1
• Intubate and maintain normocapnia (avoid hypocapnia which causes cerebral vasoconstriction and ischemia) 1

Critical Timing Considerations

The traditional teaching that surgery within 4 hours improves outcomes has been challenged. The extent of underlying brain injury and ability to control intracranial pressure (ICP) are more critical to outcome than absolute timing of clot removal 3. However, this does not justify delay—operate urgently once the decision is made 1.

Prognostic Factors (Not Timing)

Poor outcomes correlate with: 3

• Age >65 years
• Admission Glasgow Coma Scale (GCS) 3-4
• Post-operative ICP >45 mmHg
• Motorcycle accidents as mechanism

Chronic Subdural Hematoma Management

First-Line Surgical Approach

• Burr hole drainage is the preferred surgical treatment for symptomatic chronic SDH 2
• Place a subdural drain during surgery to reduce recurrence rates 2
• Reserve craniotomy only for acute-on-chronic SDH with solid components that cannot drain through burr holes 2

Conservative Management Criteria

Conservative management with close monitoring is appropriate for: 2

• Stable patients with no significant neurological deficits
• Small or asymptomatic hematomas
• Patients with stable mixed-density collections showing no progression

Monitor neurological status at least every 4 hours initially 2

Medical Therapy Options

• Tranexamic acid (750mg orally daily) can resolve chronic SDH without surgery in selected non-emergency cases 4
• This works by inhibiting fibrinolytic and inflammatory systems that perpetuate hematoma liquefaction 4, 5
• Dexamethasone should be used with caution only in selected patients due to significant side effects 5
• Atorvastatin and ACE inhibitors have uncertain clinical benefit 5

Special Situations

Subdural Hematoma After Spinal Anesthesia

• Treat with epidural blood patch (EBP) as initial therapy 6, 7
• Maintain supine position with head elevated as comfortable 6
• Burr hole drainage only if symptomatic with significant mass effect despite EBP 6
• Advise bed rest in supine position as much as possible 6

Anticoagulation Management Post-SDH

The decision to restart anticoagulation must weigh thrombotic risk against rebleeding risk: 1

• For mechanical heart valves: 2.9% ischemic event risk within 30 days off warfarin
• For atrial fibrillation with prior embolic stroke: 2.6% risk
• Median safe duration off warfarin is 10 days (range 7-19 days) with minimal ischemic events 1
• No patient had recurrent ICH when warfarin was restarted during hospitalization 1

Hydrocephalus Management

• Perform external ventricular drainage (EVD) for acute symptomatic hydrocephalus 1
• EVD alone may be harmful in posterior fossa SDH with compressed basal cisterns—perform hematoma evacuation instead 1
• Chronic symptomatic hydrocephalus requires permanent CSF diversion 1

Post-Operative Management

ICP Control

• Monitor ICP and treat elevations aggressively—post-operative ICP >45mmHg predicts poor outcome 3
• Consider repeat imaging if neurological deterioration occurs 2

Activity Restrictions (Post-EBP for Spinal Anesthesia Cases)

• Lie flat as much as possible for 1-3 days 6
• Minimize bending, straining, stretching for 4-6 weeks 6
• Consider thromboprophylaxis during immobilization 6

Critical Pitfalls to Avoid

• Do not delay surgery in neurologically deteriorating patients—this leads to worse outcomes 2
• Do not use EVD alone for posterior fossa SDH with brainstem compression—evacuate the hematoma 1
• Do not induce hypervolemia—maintain euvolemia only 2
• Do not assume advanced age (>80 years) automatically precludes surgery—base decisions on clinical status 2
• Do not use fresh frozen plasma when prothrombin complex concentrate is available for INR reversal—it acts faster 1