eMedicine Specialties > Neurosurgery > Trauma

Subdural Hematoma: Follow-up

Author: Herbert H Engelhard III, MD, PhD, FACS, Director, UIC Neuro-Oncology Program, Chief, Division of Neuro-Oncology, Associate Professor, Department of Neurosurgery, University of Illinois at Chicago
Coauthor(s): Grant P Sinson, MD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin; G Timothy Reiter, MD, Assistant Professor, Department of Neurosurgery, Penn State College of Medicine; Director, Department of Spinal Neurosurgery and Neurotrauma, Penn State Hershey Medical Center
Contributor Information and Disclosures

Updated: Jul 31, 2009

Outcome and Prognosis

Acute subdural hematoma

The mortality rate of acute subdural hematoma (SDH) has been reported to range from 36-79%. Many survivors do not regain previous levels of functioning, especially after an acute SDH severe enough to require surgical drainage. Favorable outcome rates after acute SDH range from 14-40%.

Several series have shown an increase in favorable outcome in younger patients.20 Ages younger than 40 years were associated with a mortality rate of 20%, whereas ages of 40-80 years were associated with a mortality rate of 65%. Ages older than 80 years carried a mortality rate of 88%.

Findings demonstrated by CT scan (or MRI) may help indicate prognosis. Such findings may include the thickness or volume of the hematoma, the degree of midline shift, the presence of associated traumatic intradural lesions, and the compression of the brainstem or basal cisterns.21 The first CT scan may underestimate the size of parenchymal contusions.

Elevated ICP postoperatively indicates a poor prognosis and may indicate the severity of the underlying brain injury (eg, trauma, secondary infarction).

In general, a poor preoperative neurologic status may be a harbinger of a poor outcome. In addition to factors discussed above, poor prognostic indicators for acute SDH have been reported to include the initial and postresuscitation Glasgow coma scale (GCS), the GCS motor score on admission, pupillary abnormalities, alcohol use, injury by motorcycle, ischemic damage,22 hypoxia or hypotension, and overall ability to control ICP.23,24,21

Regarding surgical timing, the adage "the sooner the surgery is done, the better" may not always be accurate. This is for various reasons and depends on the individual case.24 Even 15 years ago, Wilberger and colleagues concluded that "the time from injury to operative evacuation of the acute SDH in regard to outcome morbidity and mortality was not statistically significant when examined at hourly intervals".23 However, in patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.13

Chronic subdural hematoma

Outcome after drainage of a chronic SDH has also been found to correlate with preoperative neurologic status (see Image 5). Early diagnosis before a significant neurologic deterioration may correlate with a more favorable prognosis. No correlation has been found between preoperative CT scan findings and postoperative outcome.

The mortality rate within 30 days of surgery is 3.2-6.5%. Eighty percent of patients resume their prehematoma level of function. Sixty-one percent of patients aged 60 years or younger and in 76% of patients older than 60 years have favorable outcomes. In a relatively recent series, 89.4% of patients with chronic SDH who were treated with a closed drainage system had a good recovery and 2.2% worsened.25 Mori et al found that old age, pre-existing cerebral infarction, and subdural air after surgery correlated with poor brain expansion.26 Stanisic et al (2005) reported a 14.9% postoperative recurrence rate; various factors were associated with this.26

Future and Controversies

Although surgical intervention may be able to successfully remove the hematoma itself, patients with acute subdural hematomas (SDHs) are often difficult to treat and may have a poor outcome due to underlying brain injury. The medical issues, especially in older patients with SDH, may be complex.

The mechanism, exact pathophysiology, and optimal treatment for chronic SDH has still not been definitively determined. Further work in delineating why membranes form and how to prevent or reverse their formation may lead to improvements in treatment strategies.

Future studies of patients with brain injuries, including those who have SDH, will hopefully lead to improved strategies for prevention of secondary injury and improved recovery from the primary brain injury.

 


More on Subdural Hematoma

Overview: Subdural Hematoma
Workup: Subdural Hematoma
Treatment: Subdural Hematoma
Follow-up: Subdural Hematoma
Multimedia: Subdural Hematoma
References
Further Reading
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References

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Further Reading

Clinical guidelines

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE, Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery 2006 Mar;58(3 Suppl):S2-16-S2-24. 13

Davis PC, Seidenwurm DJ, Brunberg JA, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ, Zimmermam RD, McDermot MW, Sloan MA, Expert Panel on Neurologic Imaging. Head trauma. ACR Appropriateness Criteria® head trauma [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 12 p.

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Keywords

subdural hematoma, SDH, subdural hematomas, subdural hemorrhage, subdural hemorrhages, acute subdural hematoma, ASDH, subacute subdural hematoma, chronic subdural hematoma, CSDH, intracranial hemorrhage, brain bleed, brain bleeding, contralateral hematoma, subdural hygroma, dementia

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Contributor Information and Disclosures

Author

Herbert H Engelhard III, MD, PhD, FACS, Director, UIC Neuro-Oncology Program, Chief, Division of Neuro-Oncology, Associate Professor, Department of Neurosurgery, University of Illinois at Chicago
Herbert H Engelhard III, MD, PhD, FACS is a member of the following medical societies: American Association for Cancer Research, American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, American Society for Cell Biology, Chicago Medical Society, Congress of Neurological Surgeons, Illinois State Medical Society, Society for Neuro-Oncology, and Society for Neuroscience
Disclosure: Nothing to disclose.

Coauthor(s)

Grant P Sinson, MD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin
Grant P Sinson, MD is a member of the following medical societies: American Association of Neurological Surgeons and American Medical Association
Disclosure: Nothing to disclose.

G Timothy Reiter, MD, Assistant Professor, Department of Neurosurgery, Penn State College of Medicine; Director, Department of Spinal Neurosurgery and Neurotrauma, Penn State Hershey Medical Center
G Timothy Reiter, MD is a member of the following medical societies: American Association of Neurological Surgeons
Disclosure: Synthes Spine Consulting fee Consulting; Integra Grant/research funds None

Medical Editor

Paul L Penar, MD, Professor, Department of Surgery, Division of Neurosurgery, University of Vermont School of Medicine
Paul L Penar, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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