Clinical Treatment of Subdural Hematoma
Immediate Surgical Indications
Burr hole drainage is the preferred first-line surgical treatment for symptomatic chronic subdural hematomas, while acute subdural hematomas with significant mass effect require immediate craniotomy with clot evacuation and frequently decompressive craniectomy. 1, 2
Acute Subdural Hematoma
Immediate surgical evacuation is indicated for patients with rapidly deteriorating neurological exam, unilaterally or bilaterally dilated nonreactive pupils, extensor posturing, hematomas >10 mm thickness, or >5 mm midline shift 2, 3
Craniotomy with clot evacuation is the required approach for acute subdural hematomas associated with significant mass effect and cerebral edema 3
Primary decompressive craniectomy should be considered when significant brain swelling is present, though practice varies substantially between centers (median odds ratio 2.68) 4, 2
Patients presenting with altered consciousness require urgent assessment using Glasgow Coma Scale motor score and pupillary examination to determine surgical urgency 1, 2
Chronic Subdural Hematoma
Burr hole drainage with subdural drain placement is the first-line treatment for symptomatic chronic subdural hematomas presenting with altered consciousness, headache, or neurological deficits 1, 2
Subdural drain placement during surgery significantly reduces recurrence rates (RR 0.46,95% CI 0.27-0.76) 5
Percutaneous bedside twist-drill drainage is equally effective as operating room burr hole evacuation for chronic subdural hematomas, with no significant differences in mortality, morbidity, cure, or recurrence rates, and may offer cost savings 5
Single burr hole with subdural drainage has the lowest re-operation rate (5.06%) compared to other surgical approaches 6
Conservative Management
Small or asymptomatic subdural hematomas without significant neurological deficits should be managed conservatively with close neurological monitoring and serial imaging. 2
Regular neurological assessments are required to detect any deterioration 2
Maintain euvolemia—avoid both hypovolemia (which compromises cerebral perfusion) and hypervolemia (which does not improve outcomes and may cause complications) 1, 2
Serial CT imaging is necessary to monitor for progression 2
Anticoagulation Management
Rapidly reverse anticoagulation using prothrombin complex concentrate plus vitamin K for patients on anticoagulation who develop subdural hematoma 2
Anticoagulation should typically be interrupted for 7-15 days, with low risk of ischemic events during this period 2
Restart anticoagulation approximately 4 weeks after surgical removal if no ongoing fall risk or alcohol abuse is present 2
Management of Recurrent Subdural Hematomas
Recurrence occurs in 2-37% of cases after initial surgical evacuation 7
Most recurrent hematomas are successfully managed with repeat burr hole craniostomy with postoperative closed-system drainage 7
Craniotomy with or without membranectomy is reserved for refractory cases that fail minimally invasive procedures (RR 0.22 for recurrence after craniotomy vs minimally invasive procedures) 5
Risk factors for recurrence include poor brain reexpansion postoperatively, significant subdural air, greater midline shift, heterogeneous or multi-loculated hematomas, and lack of postoperative drainage 7
Special Consideration: 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, 8
Small or asymptomatic hematomas should be managed conservatively while treating the underlying CSF leak with epidural blood patch 2, 8
Symptomatic hematomas with significant mass effect may require burr hole drainage in conjunction with treating the CSF leak 2
Post-Operative Management
Maintain euvolemia and optimize cerebral perfusion 1
Do NOT use antiepileptic drugs 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 with prior epilepsy 2
Monitor for complications including acute subdural rebleeding (occurs in 2.65% of cases, higher in patients on antithrombotics) 6
Critical Pitfalls to Avoid
Never delay surgical intervention when neurological deterioration occurs, as this leads to significantly poorer outcomes 1, 2
Avoid using corticosteroids as adjuvant therapy—they are associated with higher morbidity (RR 1.97) without improvement in recurrence or cure rates 5
Do not perform craniotomy as initial treatment for chronic subdural hematomas, as it is associated with higher complication rates (RR 1.39) compared to minimally invasive procedures 5