eMedicine Specialties > Neurology > Critical Care Neurology

Subdural Hematoma: Treatment & Medication

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

Treatment

Medical Care

Although significant acute traumatic subdural hematoma requires surgical treatment, temporizing medical maneuvers can be preoperatively used to decrease intracranial pressure. These measures are germane for any acute mass lesion and have been standardized by the neurosurgical community. They are discussed only briefly.

• As with any trauma patient, resuscitation begins with the ABCs (airway, breathing, circulation).
  • All patients with a GCS score of less than 8 should be intubated for airway protection.
  • After stabilizing respiratory function, perform a brief neurologic examination. Adequate respiration should be initially addressed and maintained to avoid hypoxia. Hyperventilation can be used if a herniation syndrome is present.
  • The patient's blood pressure should be maintained at normal or high levels using isotonic saline, pressors, or both. Hypoxia and hypotension, which are particularly detrimental in patients with head injury, are independent predictors of poor outcome.¹¹
• Short-acting sedatives and paralytics should be used only when needed to facilitate adequate ventilation or when elevated intracranial pressure is suspected. If the patient exhibits signs of a herniation syndrome, administer mannitol 1 g/kg rapidly by intravenous (IV) push.
• The patient should also be mildly hyperventilated (pCO₂ ~30-35 mm Hg).
• Administer anticonvulsants to prevent seizure-induced ischemia and subsequent surges in intracranial pressure.
• Do not give steroids, as they have been found to be ineffective in patients with head injury.

Surgical Care

The indications for emergent decompression of an acute subdural hematoma have been previously addressed, and operative management is discussed here briefly.

• The standard reverse question mark incision provides wide access to the frontal, temporal, and parietal regions.
  • The patient is positioned supine with the head turned to the appropriate side. A shoulder roll is placed to help prevent jugular vein kinking. A 3-point head fixation device should be used in patients with an unstable C-spine fracture.
  • The whole head is shaved to facilitate placement of an intracranial pressure monitor on the contralateral side, if desired. Infiltrating the scalp with 1% lidocaine (with 1:100,000 epinephrine) is unnecessary, but the short time taken to do this may hasten hemostasis.
  • A reverse question mark incision is started at the level of the zygoma within 1 cm anterior to the tragus. This allows for full temporal access and minimizes the possibility of injuring the anterior branch of the facial nerve. The incision is carried down to the bone and through the temporalis muscle; Raney clips are used to maintain hemostasis.
  • The periosteum and temporalis are then reflected with a periosteal elevator. The initial burr hole is made over the zygoma.
  • The dura is opened and the clot is removed with gentle suction and irrigation. The initial burr hole allows for early subtemporal decompression to forestall or ameliorate uncal herniation; it may be made before opening the entire incision. Additional burr holes are placed at the perimeter of the exposure, as needed, to facilitate turning the bone flap with a craniotome.
  • The dura is opened in a cruciate fashion with a flap based on the sagittal sinus (see image below). The remainder of the clot is removed with biopsy forceps, irrigation, and suction.
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    An acute subdural hematoma is shown in this intraoperative photograph. Note the frontotemporoparietal flap used. The hematoma is currant jelly–like in appearance.

    [ CLOSE WINDOW ]

    

    An acute subdural hematoma is shown in this intraoperative photograph. Note the frontotemporoparietal flap used. The hematoma is currant jelly–like in appearance.

  • Bipolar electrocautery, gel foam, and absorbable cellulose (eg, Surgicel) are used to achieve hemostasis.
  • If substantial brain swelling develops, a dural augmentation patch graft is placed and the bone flap and overlying temporalis fascia are closed loosely.
  • Subdural drains, subgaleal drains, or both may be placed, if needed, and the wound is closed.
  • Santarius et al found that placement of drains after drainage of chronic subdural hematomas reduces recurrence and improves clinical outcome. Their randomized controlled trial in 269 adult patients with a chronic subdural hematoma for burr-hole drainage was stopped early because of a significant benefit in reduction of recurrence with drain placement. Hematomas recurred in 10 of 108 (9.3%) patients with a drain compared with 26 of 107 (24%) patients without a drain (P =0.003; 95% confidence index [CI], 0.14-0.70). At 6 months, mortality rates were 8.6% in treated patients and 18.1% in controls (P =0.042; 95% CI, 0.1-0.99).¹²
• This standard trauma craniotomy flap, which was developed in the pre/early CT era, exposes most acute traumatic subdural hematomas. However, today's rapid CT scanners almost always elucidate the subdural hematoma's location preoperatively. Therefore, linear incisions have become effective surgical options in trauma cases.
• Linear incisions may offer advantages over the standard reverse question mark incision. Because they are shorter for a given size bone flap and less time is spent controlling bleeding, linear incisions reduce surgical time. They may be extended easily across the midline to control bleeding from a distant, intraoperatively identified source. Linear incisions also eliminate issues regarding a vascular pedicle. If the cerebellar retractors used to keep the incision open are placed in a crossed axis configuration (ie, to maintain a hexagonal opening), Raney clips may be unnecessary.
• Exploratory burr holes are rarely indicated but sometimes may be used as life-saving measures. Patients with head injury can be rapidly triaged and evacuated to trauma centers with CT scanners, making exploratory burr holes a thing of the past. However, burr holes can be used for emergent decompression in patients who show signs of rapid herniation if circumstances prevent access to radiographic studies.
• Acute traumatic subdural hematomas are often associated with acute brain swelling. Ironically, rapid decompression of acute traumatic subdural hematomas via craniotomy in these patients may potentiate damage to the brain by allowing it to herniate through the craniotomy defect. A novel method of decompression was devised to prevent the brain from extruding through the craniotomy defect. This entails proceeding with the standard trauma craniotomy exposure but fenestrating the dura in a meshlike fashion rather than opening it. The clot can then be removed through the small dural openings. In a series of 31 patients operated on in this manner more than 80% of the clot was removed in 29 patients as demonstrated by CT. Eighty seven percent of patients had presented with a GCS of 8 or less, and the mortality rate for that series of patients was 52%.¹³
• Symptomatic chronic subdural hematoma is surgically treated. Craniotomy is a valid option; however, burr hole drainage and twist drill craniotomy are less invasive and appear to be equally effective. They also can be performed using local anesthesia.
  • One or 2 burr holes are placed over the thickest aspects of the hematoma. Many surgeons place frontal and parietal burr holes that later can be incorporated into a frontotemporoparietal craniotomy, if needed. The dura is opened in a cruciate fashion, and the dural leaves are coagulated. A thin rubber catheter, often a ventriculostomy catheter, is carefully placed in the subdural space. Residual subdural hematoma is gently irrigated with saline solution until the irrigant is clear. The rubber catheter is redirected to different areas of the subdural space to irrigate the hematoma. Often, the brain does not re-expand right away. In these circumstances, the rubber catheter may be tunneled under the skin and left as a subdural drain. It is then connected to a closed drainage system placed at the level of the ear or slightly lower.
  • When a twist drill is used, a hole is drilled at a 45° angle to the skull over the thickest part of the hematoma (unless this lies over the motor strip). The twist drill is used to perforate the dura and to release the subdural hematoma. A thin rubber catheter is gently guided into the subdural space, tunneled under the scalp, and brought out through a stab incision. It is connected to a closed drainage system that is set at the level of the ear or slightly below the craniotomy.
  • Hwang et al evaluated external carotid angiograms and skull radiographs to develop an optimal entry point for twist drill craniostomy. After finding that all branches of the middle meningeal artery and vascular grooves were located posterior to the coronal suture, they determined that the optimal entry point should be 1 cm anterior to the coronal suture at the level of the superior temporal line.¹⁴
  • Laying the patient flat postoperatively was previously believed to promote brain re-expansion. However, Miele et al found that hematoma recurrence and complication rate appeared to be unaffected by keeping a patient flat in bed or raising the head of the bed to 30º.¹⁵ Postoperative CT scans often show a residual subdural fluid collection that usually should be left alone unless it continues to exert significant mass effect.
  • Evacuating chronic subdural hematoma via burr holes or twist drill craniotomy is a simple task for the neurosurgeon, but complications are not uncommon. The most common complications include reaccumulation of the hematoma, intracerebral hemorrhage caused by sudden brain shift or misguided irrigation and drainage tubes, tension pneumocephalus, seizures, and subdural empyemas. However, success rates are high; 86-95% of patients are adequately treated after one procedure.¹⁶

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