From the Guidelines
Surgical intervention, specifically primary decompressive craniectomy, is the recommended treatment for acute subdural hematoma (ASDH) due to its effectiveness in reducing morbidity and mortality, as evidenced by a recent study published in The Lancet Neurology 1. The treatment approach for subdural hematomas varies based on the severity of the condition and the presence of symptoms.
- Small, asymptomatic subdural hematomas may be managed conservatively with regular monitoring and follow-up imaging to assess for resolution.
- However, for acute subdural hematomas, the evidence suggests that surgical intervention is often necessary, with primary decompressive craniectomy being a preferred method in many cases, as it allows for the removal of the hematoma and decompression of the brain, thereby reducing intracranial pressure and potentially improving outcomes. The study published in The Lancet Neurology 1 highlights the variation in surgical practices for ASDH across different centers, with the proportion of patients undergoing acute surgery ranging from 7% to 52%, and the proportion of primary decompressive craniectomies ranging from 6% to 67%.
- The median odds ratio (MOR) for acute surgery in ASDH was 1.84, indicating significant variation in surgical practices, and the adjusted MOR for primary decompressive craniectomies was 2.68, suggesting an almost three-fold difference in the likelihood of a patient receiving this type of surgery in different centers. Given the potential for significant morbidity and mortality associated with ASDH, primary decompressive craniectomy is a recommended treatment approach, as supported by the most recent and highest quality evidence 1.
- Post-surgical care should include supportive measures such as pain management, seizure prophylaxis, and gradual mobilization, as well as close monitoring for potential complications and follow-up imaging to ensure complete resolution of the hematoma.
From the Research
Subdural Hematoma Treatment Options
- Surgical management is one of the primary options for the treatment of subdural hematomas, particularly for acute subdural hematomas (ASDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan 2
- Different surgical techniques have been advocated for the evacuation of ASDH, including large craniotomy, small craniotomy, or endoscopic burr-hole evacuation 3
- Medical management of subdural hematomas focuses on managing intracranial hypertension, maintaining adequate cerebral perfusion, preventing seizures, and maintaining normothermia, eucarbia, euglycemia, and euvolemia 4
Surgical Intervention
- A wide craniotomy covering the hematoma is recommended for the evacuation of acute epidural hematoma (AEDH) to control bleeding and prevent blood reaccumulation 3
- Combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures can enable safe surgical intervention in cases of AEDH with sinus injuries 3
- Direct surgical management options for subdural hematomas include open craniotomy, twist-drill, and burr-hole drainage, as well as the usage of subdural drainage systems 5
Patient Management
- Patients with subdural hematomas require close monitoring and management in the neurocritical care setting, including initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring 5
- Post-operatively, patients with subdural hematomas require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness 4