What is the medical management for an adult or adolescent patient with a history of head trauma and a diagnosed subdural hematoma?

Medical Management of Subdural Hematoma

The medical management of subdural hematoma centers on aggressive hemodynamic optimization, intracranial pressure control, and close neurological monitoring, with immediate neurosurgical consultation for life-threatening lesions. 1

Initial Stabilization and Hemodynamic Management

Blood Pressure Targets

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions and throughout the acute phase 1, 2
• After ICP monitor placement, target cerebral perfusion pressure (CPP) between 60-70 mmHg 2
• Avoid CPP >70 mmHg routinely, as CPP >90 mmHg worsens neurological outcomes due to vasogenic cerebral edema 2

Respiratory Management

• Maintain PaO2 between 60-100 mmHg to ensure adequate oxygenation without hyperoxia 1, 2
• Target PaCO2 between 35-40 mmHg (normocapnia) during all interventions 1, 2
• Reserve hypocapnia (temporary hyperventilation) only for cases of cerebral herniation while awaiting emergency neurosurgery 1, 2

Hematologic Optimization

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions 1, 2
• Higher transfusion thresholds may be appropriate in elderly patients or those with cardiovascular disease 1
• Maintain platelet count >50,000/mm³ for systemic hemorrhage control 1, 2
• For patients requiring emergency neurosurgery or ICP probe insertion, higher platelet values are advisable 1
• Maintain PT/aPTT <1.5 times normal control during all interventions 2

Anticoagulation and Antiplatelet Management

Immediate Reversal

• Hold aspirin immediately upon diagnosis of subdural hematoma, as elderly patients (≥65 years) on aspirin have a 3-fold increased risk of hemorrhage progression (26% vs 9% in non-anticoagulated patients) 3
• Reverse anticoagulation immediately if the patient is on warfarin, NOACs, or antiplatelet agents 4

Common Pitfall

• The presence of a documented subdural hematoma changes the risk-benefit calculation significantly—do not continue anticoagulation or antiplatelet therapy based on cardiovascular indications 3

Intracranial Pressure Management

ICP Monitoring Indications

• All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension require ICP monitoring regardless of whether they undergo emergency neurosurgery or extra-cranial surgery 1, 2
• Patients at risk for intracranial hypertension without a life-threatening intracranial mass lesion or after emergency neurosurgery require ICP monitoring 1, 2
• Intraparenchymal probes are preferred over ventricular catheters due to better risk-benefit profile, though catheter placement failure occurs in 10% of cases 2

Osmotherapy

• In cases of cerebral herniation, use osmotherapy (mannitol) and/or temporary hypocapnia while awaiting emergency neurosurgery 1, 5
• Mannitol is FDA-indicated for reduction of intracranial pressure and brain mass 5

Medication to Avoid

• Do not use corticosteroids (such as dexamethasone) for traumatic brain injury management, as they may worsen outcomes 3

Neurological Monitoring Protocol

Initial Assessment

• All patients require urgent neurological evaluation including pupil examination, Glasgow Coma Scale motor score, and brain CT scan to determine severity 1, 2

Serial Monitoring for Admitted Patients

• Monitor GCS every 15 minutes for the first 2 hours, then hourly for the following 12 hours 3
• Document individual GCS components (Eye, Motor, Verbal) and pupillary size/reactivity at each evaluation 3
• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning 3

Repeat Imaging Strategy

• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 3
• Consider repeat imaging at 4-6 weeks to ensure resolution or stability 2

Admission and Observation Requirements

Mandatory Admission Criteria

• Any documented subdural hematoma on CT requires admission, regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 3
• Admit patients for close neurological observation for 24-72 hours with serial clinical assessments 3
• Even patients with normal neurological examinations should not be discharged with documented subdural hematomas due to risk of delayed deterioration requiring neurosurgery 1, 3

Exception for Very Small Hematomas

• No patient with an initial SDH ≤3 mm required surgery in recent studies, although 11.1% enlarged (maximum width 10 mm) 6
• However, these patients still require admission and monitoring given the risk of expansion 6

Critical Thresholds for Neurosurgical Consultation

Immediate Neurosurgical Intervention Required

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 1
• Development of pupillary changes or posturing indicating herniation 3
• GCS decline of ≥2 points 3
• Development of focal neurological deficits indicating mass effect 3
• Midline shift >5 mm with low GCS scores 4
• SDH thickness >5 mm with midline shift >5 mm 4

Timing Considerations

• An 8.5-mm initial SDH size threshold best predicted the need for surgical intervention 6
• Surgical evacuation should be performed as soon as possible after the decision is made, as delaying surgery in patients with significant midline shift and low GCS scores is associated with poorer outcomes 4
• While earlier surgery may improve outcomes, the extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome 7

Common Pitfalls to Avoid

• Do not discharge patients with documented subdural hematomas based solely on normal neurological examination 3
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 3
• Do not fail to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 3
• Do not delay correction of secondary insults (hypotension, hypoxia) while monitoring 3
• Do not delay transfer for "medical optimization" beyond basic resuscitation in patients requiring neurosurgical intervention, as this is a time-critical emergency 4

Risk Factors for Hematoma Expansion

• Larger initial SDH size, concurrent subarachnoid hemorrhage, hypertension, convexity location, and midline shift are significantly associated with hematoma expansion 6
• These patients require particularly vigilant monitoring and lower threshold for repeat imaging 6