What is the plan of care for a patient with a subdural hemorrhage?

Management of Subdural Hemorrhage

Patients with subdural hemorrhage require immediate airway stabilization with tracheal intubation and mechanical ventilation, strict blood pressure control (SBP >110 mmHg, avoiding <90 mmHg), and urgent transfer to a neurosurgical center, with surgical evacuation indicated for hematomas >5 mm thickness with >5 mm midline shift or any symptomatic patient with neurological deterioration. 1, 2, 3

Immediate Stabilization and Resuscitation

Airway Management

• Perform immediate tracheal intubation with mechanical ventilation and continuous end-tidal CO₂ monitoring starting in the pre-hospital phase to reduce mortality and prevent secondary brain injury 1, 4
• Maintain PaCO₂ within normal range (35-40 mmHg) as hypocapnia causes cerebral vasoconstriction and brain ischemia 1, 4, 3
• End-tidal CO₂ monitoring confirms correct tube placement and guides ventilation targets 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine) without delay 1, 4
• Even a single episode of hypotension (SBP <90 mmHg) significantly worsens neurological outcomes 1, 4
• Use continuous infusions of sedatives rather than boluses to prevent hemodynamic instability 1, 4

Anticoagulation Reversal

• Rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K for patients on anticoagulation 2
• Interrupt anticoagulation for 7-15 days, with low risk of ischemic events during this period 2

Transfer and Systems of Care

Urgent Transfer Indications

• Transfer acute subdural hematoma with mass effect as a time-critical transfer to neurosurgical center 3
• Transfer should occur even before complete stabilization in time-critical cases 3

Pediatric Considerations

• Acute subdural hematoma with mass effect requires time-critical transfer by local team rather than waiting for specialized pediatric transport 3
• Transfer team should include an anesthetist with pediatric training when possible 3

Surgical Indications and Timing

Absolute Indications for Surgery

• Acute subdural hematoma with thickness >5 mm AND midline shift >5 mm requires immediate surgical evacuation 1, 2, 3
• Any symptomatic subdural hematoma with significant mass effect, neurological deterioration, or decreased level of consciousness requires immediate surgery 2, 1
• Standard craniotomy with hematoma evacuation remains the first-line surgical approach 1

Chronic Subdural Hematoma

• Burr hole drainage is the preferred first-line surgical approach for chronic subdural hematomas 2
• Place subdural drain to reduce recurrence rates 2

Decompressive Craniectomy

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion, particularly in patients <65-70 years 1, 3
• This is reserved for cases where standard craniotomy fails to control ICP 1, 3

Conservative Management

Criteria for Non-Operative Management

• Small hematomas (<10 cm³ blood volume) without mass effect or neurological deficits can be managed conservatively with close monitoring 2, 5
• Patients with isolated small traumatic subdural hemorrhage (<10 cm³) do not require ICU monitoring and can be managed on regular hospital units 5
• Conservative management requires regular neurological assessments, maintaining euvolemia, and serial imaging to monitor for progression 2

Monitoring Requirements

• Patients with small subdural hemorrhage and additional intracranial hemorrhages show low rates of decline (4% medical, 4% neurological) but may benefit from ICU observation 5
• Subdural hematomas >10 cm³ demonstrate poor clinical courses and require ICU monitoring 5

Post-Operative Management

ICP Monitoring Indications

• Monitor ICP after subdural hematoma evacuation if ANY of the following are present: 1, 4
  • Preoperative GCS motor response ≤5
  • Preoperative anisocoria or bilateral mydriasis
  • Preoperative hemodynamic instability
  • Preoperative severity signs on imaging
  • Intraoperative cerebral edema
  • Postoperative appearance of new intracranial lesions

Cerebral Perfusion Goals

• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg, as CPP <60 mmHg is associated with poor outcomes 1, 4
• Target ICP <22 mmHg and MAP 80-110 mmHg 6

CSF Drainage

• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 3
• Drainage of small volumes of CSF can markedly reduce intracranial pressure 3

Seizure Management

• Antiepileptic drugs are NOT recommended for primary prevention of post-traumatic seizures as they show no benefit and may worsen neurological outcomes 2
• Consider antiepileptic drugs only if specific risk factors are present, such as chronic subdural hematoma or prior epilepsy 2

General ICU Care

• Maintain normothermia, eucarbia, euglycemia, and euvolemia 6
• Initiate early enteral feeding, mobilization, and physical therapy 6
• Use standardized ICU care bundles if mechanical ventilation required 3

Special Considerations

Subdural Hematoma in Spontaneous Intracranial Hypotension

• Perform MRI of brain with contrast and whole spine to investigate for spinal CSF leak when subdural hematoma occurs without clear trauma history 2
• Small or asymptomatic hematomas should be managed conservatively while treating the CSF leak 2
• Symptomatic hematomas with significant mass effect may need burr hole drainage in conjunction with treating the leak 2

Elderly Patients

• Require careful monitoring as small hematomas can expand rapidly, especially in those on anticoagulants 1
• Age >65 years is associated with worse outcomes 7

Critical Pitfalls to Avoid

• Never delay surgical intervention when neurological deterioration occurs as this leads to poorer outcomes 1, 2
• Never hyperventilate aggressively as this causes profound cerebral vasoconstriction and ischemia 4, 1
• Never allow even single episodes of hypotension (SBP <90 mmHg) which markedly worsens prognosis 1, 4
• Never use sedation boluses instead of continuous infusions as this causes hemodynamic instability 1, 4
• Never induce hypervolemia as it does not improve outcomes and may cause complications 3, 2