From the Guidelines
A hematoma requires immediate surgical intervention when it causes significant mass effect, neurological deficits, or continues to expand, and a stat MRI is indicated for patients with deteriorating neurological status, suspected expanding hematoma, or when the location and extent need precise evaluation for surgical planning. The management of hematoma is a medical emergency, characterized by high morbidity and mortality, which should be promptly diagnosed and aggressively managed 1. According to the guidelines for the management of spontaneous intracerebral hemorrhage, CT and magnetic resonance imaging (MRI) are both reasonable for initial evaluation, but CT is very sensitive for identifying acute hemorrhage and is considered the gold standard 1.
Key Indicators for Surgical Intervention
- Significant mass effect
- Neurological deficits
- Expanding hematoma
- Deteriorating neurological status
- Suspected secondary causes of hemorrhage, such as arteriovenous malformations (AVM), tumors, moyamoya, and cerebral vein thrombosis 1
Imaging Modalities
- CT is the preferred initial imaging modality due to its sensitivity for acute hemorrhage and availability 1
- MRI, including gradient echo (GRE) and T2*susceptibility‑weighted MRI, is more sensitive for identification of prior hemorrhage and can be used for further evaluation when necessary 1
- CT angiography (CTA) and contrast‑enhanced CT may identify patients at high risk of ICH expansion based upon the presence of contrast extravasation within the hematoma 1
Clinical Decision-Making
The decision for surgery balances the risks of the procedure against the benefits of relieving pressure on the brain tissue, improving blood flow, and preventing secondary injury from prolonged compression or herniation 1. Clinical indicators for urgent imaging and potential surgery include decreasing Glasgow Coma Scale score, pupillary abnormalities, severe headache, vomiting, seizures, or focal neurological deficits. Some smaller hematomas without significant symptoms may be managed conservatively with close monitoring, but the threshold for intervention is lower in critical locations like the posterior fossa where even small bleeds can be life-threatening.
From the Research
Hematoma Management
- Surgical intervention is a primary option for managing traumatic brain injury (TBI) and intracranial hematomas, such as acute subdural hematoma (ASDH) and acute epidural hematoma (AEDH) 2
- The decision to perform surgery depends on the type and location of the hematoma, as well as the patient's overall condition
- For spinal hematomas, management is often aimed at rapid surgical decompression and correction of the underlying etiology, if possible 3
Diagnostic Imaging
- MRI is the gold-standard for diagnosing spinal hematomas and is valuable in determining the presence, location, and extent of the hematoma 4, 5
- MRI can help differentiate between hyperacute, subacute, and chronic spinal hematomas, as well as between spinal subdural hematoma (SSH) and spinal epidural hematoma (SEH) 4, 6
- Early detection and accurate localization of spinal hematomas are critical for proper treatment and surgical decompression, if necessary 6
Surgical Indications
- Surgical intervention is typically indicated for patients with significant neurological deficits, large hematomas, or evidence of brain herniation 2
- For spinal hematomas, surgical decompression may be necessary to prevent permanent neurologic deficits 3, 6
- The decision to perform surgery should be made on a case-by-case basis, taking into account the patient's overall condition and the specific characteristics of the hematoma 2, 3