From the Guidelines
Management of subdural hemorrhage requires prompt neurosurgical evaluation and intervention, with emergency surgical evacuation via craniotomy being the primary treatment for acute subdural hemorrhages with significant mass effect, midline shift, or neurological deficits, as indicated by studies such as 1. The decision to operate is based on the severity of the hemorrhage, with a significant acute subdural hematoma being defined as one with a thickness greater than 5 mm and displacement of the median line greater than 5 mm, according to 1. Key considerations in the management of subdural hemorrhage include:
- Close neurological monitoring
- Maintaining adequate cerebral perfusion pressure (typically >60 mmHg)
- Controlling intracranial pressure (keeping it <20-25 mmHg)
- Use of osmotic agents like mannitol or hypertonic saline for increased intracranial pressure
- Seizure prophylaxis with levetiracetam or phenytoin, especially in patients with acute hemorrhages or those undergoing surgery
- Careful control of blood pressure to prevent rebleeding while ensuring adequate cerebral perfusion
- Reversal therapy for patients on anticoagulants, such as vitamin K and prothrombin complex concentrate for warfarin, protamine for heparin, and specific reversal agents for DOACs when available, as noted in 1. Post-operative monitoring of intracranial pressure is suggested after post-traumatic intracranial hematoma evacuation, including subdural hemorrhage, in cases with specific preoperative or intraoperative criteria, as outlined in 1. The underlying pathophysiology of subdural hemorrhage involves tearing of bridging veins between the brain and dural sinuses, leading to accumulation of blood in the subdural space, increased intracranial pressure, and potential brain compression. Supportive care measures, such as head elevation to 30 degrees, pain management, and prevention of complications like deep vein thrombosis and pneumonia, are also crucial in the management of subdural hemorrhage.
From the Research
Management of Subdural Haemorrhage
- The management of subdural haemorrhage (SDH) involves both medical and surgical interventions, with the goal of reducing morbidity and mortality 2.
- Initial management of patients with suspected SDH includes maintaining intracranial pressure (ICP) < 22 mmHg, cerebral perfusion pressure (CPP) > 60 mmHg, mean arterial pressure (MAP) 80-110 mmHg, and PaO2 > 60 mmHg, as well as administering anti-seizure medications and reversing antiplatelet or anticoagulant medications if necessary 2.
- Medical management of SDH focuses on:
- Managing intracranial hypertension
- Maintaining adequate cerebral perfusion
- Preventing and treating seizures
- Maintaining normothermia, eucarbia, euglycemia, and euvolemia
- Initiating early enteral feeding, mobilization, and physical therapy 2
Surgical Management
- Surgical management of SDH may involve craniotomy or decompressive craniectomy, with the choice of procedure depending on various factors, including patient age, sex, and clinical presentation 3, 4.
- Craniotomy is often preferred for patients with better clinical exams, while decompressive craniectomy may be chosen for patients with worse clinical exams and higher intracranial pressures 3.
- A systematic review and meta-analysis found that patients who underwent craniotomy had better functional outcomes compared to those who underwent decompressive craniectomy, but had a higher risk of residual subdural hematoma 4.
Considerations for Specific Patient Populations
- The management of SDH may vary depending on the patient population, with elderly and pediatric patients requiring special consideration 5.
- Patients with SDH who are taking anticoagulant or antiplatelet medications may require reversal of these medications, and those with recurrent or recalcitrant SDH may require more aggressive management 5.
- The use of subdural drainage systems and other surgical techniques, such as twist-drill and burr-hole drainage, may also be considered in the management of SDH 5, 6.