eMedicine Specialties > Neurology > Critical Care Neurology

Subdural Hematoma: Follow-up

Author: Richard J Meagher, MD, Attending Neurosurgeon, Neurosurgical Associates of Abington, Abington Memorial Hospital
Coauthor(s): William F Young, MD, Attending Neurosurgeon, Fort Wayne Neurological Center
Contributor Information and Disclosures

Updated: Nov 24, 2009

Follow-up

Prognosis

  • When deciding whether to operate, consider the patient's prognosis. The ideal is to maximize the likelihood of appropriate resource allocation and, more importantly, allow for appropriate family counseling; keep in mind that no method of assessing the prognosis is 100% accurate.
  • In a retrospective review of 109 consecutive patients with head injury with a CT scan diagnosis of acute traumatic subdural hematoma, Phuenpathom et al found that poor outcome was strongly correlated with the best sum GCS score within the first 24 hours of head injury and pupillary inequality. Age and pupillary reaction to light also correlated well with the outcome. The mortality rate in the whole series was 50%. The mortality rate for all 37 patients with a GCS score of 3 was 100%, and this rate decreased as the GCS increased. The mortality rate for those with unequal pupils was 64%, compared to 40% for those with equal pupils. The mortality rate associated with one nonreactive pupil was 48% and 88% with bilateral nonreactive pupils. Interestingly, the survival rate for patients with bilateral nonreactive pupils was 12%, although their outcome status was not noted.17
  • Wilberger et al also found an 88% mortality rate associated with fixed, dilated pupils and noted a 7% functional recovery associated with this finding. This study found that neurological presentation and postoperative intracranial pressure (not evaluated by Phenpatham et al) were strong predictors of outcome. Wilberger et al also found a trend of increasing mortality rate with age, although it was not statistically significant.18
  • Sakas et al examined 1-year outcomes following craniotomy for traumatic hematomas in patients with fixed, dilated pupils. Their results suggested that the presence of an acute subdural hematoma was the single most important predictor of a negative outcome in patients with fixed and dilated pupils. Patients with subdural hematomas had a mortality rate of 64% compared with a mortality rate of 18% in patients with extradural hematomas.19
  • Seelig et al also showed that neurologic examination and postoperative intracranial pressure were important prognostic factors. The peak intracranial pressure was less than 20 mm Hg in 53% of patients with acute traumatic subdural hematoma (similar to 59% of patients with other types of head injuries), but this group accounted for 79% of the patients with functional recoveries. All patients with uncontrollably elevated intracranial pressure (>60 mm Hg) died. These authors claimed a 25% functional recovery rate (defined by the Glasgow Outcome Scale) in patients presenting with fixed, dilated pupils.20
  • Although rare, acute subdural hematomas that would otherwise be considered operative by imaging criteria may possibly resolve on their own. A series of 4 such patients was reported by Kapsalaki et al.21
  • No clear prognostic factors are associated with chronic subdural hematoma. While some authors have found an association with preoperative level of neurological function and outcome, others have not.
  • Between 86% and 90% of patients with chronic subdural hematoma are adequately treated after one surgical procedure.

Patient Education

For excellent patient education resources, visit eMedicine's Headache Center. Also, see eMedicine's patient education article Aneurysm, Brain.

Miscellaneous

Medicolegal Pitfalls

Inadequate discharge instructions for patients discharged from the hospital after sustaining a very small acute traumatic subdural hematoma may not prompt a patient to return to the emergency department in a timely manner if symptoms progress or develop. Inadequate assessment and surveillance of patients admitted to the hospital might lead to missed opportunities for care in patients who are still at risk for delayed neurologic deterioration. This can result in morbidity or death as subsequent herniation occurs.

  • The legal liability in such a situation is unavoidable. The patient returning home from the emergency department needs to be able to solicit help from another person who is competent to provide assistance and lives with the patient. A surveillance plan ("head injury check list"), designed to show clear signs of potential herniation, needs to be given to the patient and caregiver with clear indications of when to return to the emergency department.
  • Likewise, a patient with head trauma admitted to the hospital needs to have explicit nursing orders for neurologic examinations ("neuro checks") to be followed at frequent (30-60 min) intervals with instructions to call the clinician with any significant changes in neurological status. Such follow-up care should eliminate any ambiguity that later compromises the practitioner's position in a litigation response and, most of all, establishes a required pattern of immediate follow-up care.

Acute traumatic subdural hematomas have been observed to develop in a delayed fashion. Itshayek et al presented 4 patients that developed acute traumatic subdural hematoma after sustaining mild traumatic brain injury and having a normal initial CT scan of the head. All 4 patients had been on anticoagulant or antiaggregation therapy. Three of the 4 required craniotomy for evacuation of their hematomas. Elderly anticoagulated patients with mild traumatic brain injury might warrant a longer period of clinical observation.22

 


More on Subdural Hematoma

Overview: Subdural Hematoma
Differential Diagnoses & Workup: Subdural Hematoma
Treatment & Medication: Subdural Hematoma
Follow-up: Subdural Hematoma
Multimedia: Subdural Hematoma
References
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References

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Further Reading

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Keywords

head injury, subdural hematoma, epidural hematoma, extraaxial hematoma, intracranial mass lesions, head injuries, intracranial hematomas, traumatic intracranial hematomas, chronic subdural hematoma, CSDH, coagulopathies and ruptured intracranial aneurysms, acute traumatic subdural hematoma, ATSDH, atraumatic subdural hematoma, acute subdural bleeding, brain injury, cerebral atrophy, herniation syndromes, stroke of the posterior cerebral artery distribution, spontaneous subdural hematoma

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Contributor Information and Disclosures

Author

Richard J Meagher, MD, Attending Neurosurgeon, Neurosurgical Associates of Abington, Abington Memorial Hospital
Richard J Meagher, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

William F Young, MD, Attending Neurosurgeon, Fort Wayne Neurological Center
William F Young, MD is a member of the following medical societies: Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Norman C Reynolds Jr, MD, Neurologist, Veterans Affairs Medical Center of Milwaukee; Professor Medical College of Wisconsin (retired)
Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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