How should an acute subdural hematoma with a 6 mm midline shift be managed?

Management of Acute Subdural Hematoma with 6mm Midline Shift

An acute subdural hematoma with 6mm midline shift requires urgent surgical evacuation via craniotomy or decompressive craniectomy, as this exceeds the 5mm threshold for mandatory surgical intervention. 1, 2

Immediate Pre-Surgical Stabilization

Before proceeding to the operating room, three critical interventions must occur simultaneously:

• Secure the airway immediately through rapid-sequence endotracheal intubation with mechanical ventilation, confirming correct tube placement via end-tidal CO2 monitoring to maintain PaCO2 within normal range. 1, 2, 3

• Maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine) without any delay—even a single episode of SBP <90 mmHg markedly worsens neurological outcome. 1, 2, 3

• Administer vasopressors immediately rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 1, 2

Surgical Indication and Timing

Your patient meets absolute criteria for emergency surgical evacuation:

• Midline shift >5mm is an absolute indication for surgery, regardless of Glasgow Coma Scale score or presence of focal deficits. 2, 4

• Acute subdural hematoma with thickness >5mm AND midline shift >5mm requires immediate craniotomy or decompressive craniectomy. 2

• The proportion of patients with acute subdural hematoma undergoing acute surgery ranges from 7% to 52% between centers, with significant variation in whether primary decompressive craniectomy versus craniotomy is performed. 5

Surgical Approach Selection

The choice between craniotomy and decompressive craniectomy depends on clinical presentation:

• Consider primary decompressive craniectomy if the patient presents with GCS ≤8, signs of intracranial hypertension, or significant brain swelling on CT beyond the hematoma itself. 5, 1

• Standard craniotomy with hematoma evacuation is appropriate for patients with better neurological status (GCS >8) without severe underlying brain injury or refractory elevated ICP. 5

• Decompressive craniectomy without hematoma evacuation has been studied in small cohorts with recalcitrant elevated ICP, showing potential benefit, but hematoma evacuation plus decompression is generally preferred. 5

Post-Operative Management

After surgical evacuation, aggressive monitoring and supportive care are mandatory:

• Implement intracranial pressure monitoring in all patients who cannot be neurologically assessed post-operatively to detect intracranial hypertension and guide pressure-directed therapy. 1, 2

• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is established, adjusting based on individual autoregulation status. 1, 2

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 3

• Use propofol by continuous infusion (never bolus) to control ICP while avoiding hemodynamic instability. 1

• Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes. 1

Critical Pitfalls to Avoid

Several common errors can worsen outcomes:

• Never delay intubation to rush to surgery—aspiration, hypoxemia, or hypercarbia during transport will worsen neurological outcomes; the airway must be secured first. 2

• Never use bolus sedation instead of continuous infusions, which causes hemodynamic instability. 1, 3

• Never delay transfer to a neurosurgical center for "stabilization" at a non-neurosurgical facility—rapid transport to definitive care is essential. 1, 2, 3

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors. 3

Conservative Management is NOT an Option

While some studies have explored conservative management of acute subdural hematoma, your patient does not qualify:

• Conservative management may be considered only for patients with midline shift <5mm, GCS 15, no focal deficits, and open cisterns on CT. 6, 7

• Patients with midline shift >5mm who are managed conservatively typically deteriorate within 3 days and require urgent surgery. 6

• With 6mm midline shift, the cerebral compensatory mechanism is already exhausted, making conservative management inappropriate regardless of current GCS score. 6