From the Guidelines
The size of a subdural hematoma is a critical factor in determining the management and prognosis of patients with traumatic brain injury (TBI), with hematomas larger than 25 mL often necessitating surgical intervention due to the high risk of uncontrollable intracranial hypertension and poor outcomes 1.
Key Considerations
- The volume of the hematoma is a significant predictor of the need for surgical intervention, with larger hematomas associated with higher mortality rates and poorer functional outcomes.
- The rate of hematoma expansion, neurological status of the patient, and presence of mass effect are equally important considerations in determining the management of subdural hematomas.
- Patients with smaller hematomas who are neurologically intact may be observed with serial imaging, while those with larger hematomas or neurological deficits require more aggressive management.
Management Recommendations
- Subdural hematomas larger than 25 mL should be considered for surgical evacuation due to the high risk of uncontrollable intracranial hypertension and poor outcomes 1.
- Monitoring of intracranial pressure (ICP) is recommended after post-traumatic intracranial hematoma evacuation in patients with preoperative Glasgow Coma Scale motor response inferior or equal to 5, preoperative anisocoria or bilateral mydriasis, preoperative hemodynamic instability, or preoperative severity signs on cerebral imaging 2.
- Close monitoring of patients with subdural hematomas is essential, regardless of initial size, due to the risk of rapid growth and potential for life-threatening complications.
From the Research
Significance of Subdural Hematoma Size in Patients with TBI
- The size of a subdural hematoma is a significant factor in determining the outcome of patients with traumatic brain injury (TBI) 3, 4.
- A larger subdural hematoma is associated with a higher risk of neurosurgical intervention and poor outcomes, including increased mortality and decreased likelihood of discharge to home 3, 4.
- The maximum hemorrhage thickness and midline shift are independent risk factors for neurosurgical intervention within 48 hours of hospital admission 3.
- Radiographic risk factors, such as maximum hemorrhage thickness and midline shift, are stronger predictors of neurosurgical intervention than demographic and clinical variables 3.
Surgical Management of Subdural Hematoma
- Surgical management of subdural hematoma is a primary option for patients with TBI, and the choice of surgical technique depends on the size and location of the hematoma 5, 6.
- Large craniotomy is often chosen for the evacuation of subdural hematoma, as it can easily be shifted to decompressive craniectomy in case of brain swelling 5.
- Small craniotomy or endoscopic burr-hole evacuation of subdural hematoma is also accepted as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates 5, 7.
Prognostic Factors for Subdural Hematoma
- The presence of an isolated subdural hematoma is more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage 4.
- The size of the subdural hematoma, as well as the patient's age and Glasgow Coma Scale (GCS) score, are important prognostic factors for outcome 3, 4.
- Consideration of subdural hematoma size and other radiographic risk factors can augment age and GCS score in classification and prognostic models for TBI 3, 4.