What is the management of subdural hematoma?

From the Guidelines

Subdural hematoma management should prioritize prompt neurosurgical evaluation and intervention based on the severity, size, and patient symptoms, with a focus on reducing morbidity, mortality, and improving quality of life. The management approach should be individualized, taking into account the patient's specific condition and the potential benefits and risks of different interventions.

Key Considerations

• Acute subdural hematomas with significant mass effect (midline shift >5mm), thickness >10mm, or causing neurological deficits typically require urgent surgical evacuation through craniotomy or burr hole drainage 1.
• For smaller, chronic subdural hematomas in stable patients, conservative management may be appropriate with close neurological monitoring, including bed rest, analgesics for headache control, and seizure prophylaxis with levetiracetam 500-1000mg twice daily for 7 days in acute cases with cortical involvement.
• Patients should be monitored for signs of deterioration, including worsening headache, altered mental status, focal neurological deficits, or pupillary changes, and serial imaging with CT scans is essential to track hematoma evolution 1.
• Anticoagulant and antiplatelet medications should be reversed or held when possible, with vitamin K 10mg IV and prothrombin complex concentrate for warfarin reversal in emergent cases, and adequate hydration and blood pressure control are important supportive measures.

Surgical Intervention

• Urgent surgical hematoma evacuation with or without external ventricular drain (EVD) is recommended for patients with cerebellar intracerebral hemorrhage who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL 1.
• The efficacy of surgical evacuation for improving functional outcomes is uncertain and has not been demonstrated in retrospective studies, highlighting the need for individualized decision-making and careful consideration of the potential benefits and risks of surgical intervention.

Monitoring and Supportive Care

• Close monitoring of patients with subdural hematomas is crucial, with regular assessments of neurological function, vital signs, and imaging studies to track hematoma evolution and detect potential complications early.
• Supportive care measures, including adequate hydration, blood pressure control, and pain management, are essential to optimize patient outcomes and reduce the risk of complications.

From the Research

Subdural Hematoma Management

• Subdural hematomas (SDH) are a common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates 2.
• The initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, focusing on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg 2.

Medical Management

• Medical SDH care focuses on:
  • Management of intracranial hypertension
  • Maintenance of adequate cerebral perfusion
  • Seizure prevention and treatment
  • Maintenance of normothermia, eucarbia, euglycemia, and euvolemia
  • Early initiation of enteral feeding, mobilization, and physical therapy 2.
• Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging 2.

Surgical Management

• An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score 3.
• Surgical evacuation of SDH is associated with favorable outcome, and patient selection for evacuation is enhanced by the application of the acute SDH score 4.
• Craniotomy for treatment of chronic subdural hematoma is a common management approach, with variations including minicraniotomy, minicraniectomy, and with or without either a partial or full membranectomy 5.

Predictors of Outcome

• Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predict undergoing surgery 4.
• The acute SDH score, which incorporates age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms, can guide surgical decision-making and predict 90-day functional outcome 4.