Treatment
Medical Therapy
Acute subdural hematoma
Emergency medical treatment of a patient with an acute subdural hematoma (SDH) that causes impending transtentorial herniation may include bolus administration of mannitol (in patients whose fluid levels have been adequately resuscitated and who have adequate blood pressure). Surgical evacuation of the lesion is the definitive treatment. Hyperventilation might be required but may decrease cerebral blood flow, thereby causing cerebral ischemia.
A patient with coagulopathy or a patient with an acute SDH who is receiving anticoagulant medication should be transfused with fresh frozen plasma (FFP), platelets, or both to maintain the prothrombin time (PT) within the reference range and the platelet count above 100,000. Heparin may need to be reversed with protamine; patients receiving warfarin are given vitamin K. Platelet infusion may also need to be considered if the platelet count is adequate but platelet function is impaired. The use of other factors, such as recombinant factor VII is under investigation. In patients who are receiving therapeutic anticoagulation, the potential effects of reversing the anticoagulation need to be considered.
The use of sequential CT scanning is important. Although each patient must be treated individually, patients who have small acute SDHs thinner than 5 mm on axial CT images without sufficient mass effect to cause midline shift or neurological signs have been observed clinically, with acceptable results (see Image 1). Hematoma resolution should be documented with serial imaging because an acute SDH that is treated conservatively can evolve into a chronic hematoma. For serial imaging, MRI may be more sensitive, but CT may be more convenient and less expensive.
Chronic subdural hematoma
In patients who have no significant mass effect on imaging studies and no neurological symptoms or signs except mild headache, chronic SDHs have been observed with serial scans and have been seen to remain stable or to resolve.
Although hematoma resolution has been reported, it cannot be reliably predicted, and no medical therapy has been shown to be effective in expediting the resolution of acute or chronic SDHs.
Surgical Therapy
Acute subdural hematoma
Surgery to manage an acute subdural hematoma (SDH) usually consists of a large craniotomy (centered over the thickest portion of the clot) to decompress the brain, to stop any active subdural bleeding, and if indicated, to evacuate intraparenchymal hematoma in the immediate vicinity of the acute SDH. An acute SDH usually has a consistency that is too firm to allow removal through burr holes alone.
Including the sylvian fissure in the craniotomy exposure should be considered, since this is a likely location of a ruptured cortical vessel. If brain injury and edema are associated with the SDH, an ICP monitor may need to be placed. Bullock and colleagues (2006) stated that "all patients with acute SDH in coma (Glasgow coma scale [GCS] score less than 9) should undergo intracranial pressure monitoring."13 Craniectomy (ie, the removal of the bone plate or flap) is also sometimes required, such as when increased ICP is present or anticipated. Different methods for storing the bone flap for possible later replacement exist.
Chronic subdural hematoma
Various surgical techniques for the treatment of chronic SDH have been described. Liquefied chronic SDHs are commonly treated with drainage through 1 or 2 burr holes. The burr holes are placed so that conversion to a craniotomy is possible, if needed. A closed drainage system is sometimes left in the subdural space for 24-72 hours postoperatively. Drainage via twist-drill craniotomy at the bedside has also been described.16,17 Recently, a new system, the Subdural Evacuating Port System, has been introduced, with encouraging results.18
Under certain circumstances, craniotomy is recommended for chronic SDH, depending on factors such as recurrence, the consistency of the hematoma, and the presence of membranes.
Bilateral chronic hematomas may require drainage from both sides, usually during the same operation by means of burr holes placed on each side of the head.
Preoperative Details
Phenytoin (Dilantin) is administered to decrease the risk of developing early posttraumatic seizures (within the first 7 d after the injury). Patients have an estimated risk of greater than 20% for developing posttraumatic epilepsy after an acute subdural hematoma (SDH). Whether this risk is modifiable with prophylactic anticonvulsants remains debatable.
Intraoperative Details
The surgical technique for removing an acute subdural hematoma (SDH) is well described in most standard texts of neurosurgery. When an acute SDH is evacuated, intraoperative ultrasonography may be helpful for locating intraparenchymal clots, which also may require evacuation, depending on the risks and benefits involved. Perioperative antibiotics may be administered to decrease the risk of postoperative infection.
Postoperative Details
Acute subdural hematoma
After the evacuation of an acute SDH, medical treatment is aimed at controlling the ICP below 20 mm Hg and maintaining the cerebral perfusion pressure above 60-70 mm Hg.
A follow-up CT scan is usually obtained within 24 hours of acute SDH removal and as needed to monitor for residual hematoma and recurrence.
If elevated ICP is an issue postoperatively, an urgent CT scan should be obtained to look for a new intracranial mass lesion or reaccumulation of the SDH.
Postoperative coagulation studies (PT, aPTT) and platelet counts should be observed closely and adjustments made, when possible, to lessen the risk of additional bleeding.
Chronic subdural hematoma
After the evacuation of a chronic SDH, adequate patient hydration is needed to help reexpand the brain. In addition, the patient may be maintained on bedrest with the head of the bed flat to aid brain reexpansion by increasing the intracranial venous pressure.
Follow-up
Acute subdural hematoma
Serial neurological examinations are used to determine the patient's subsequent clinical course (whether the patient is stable, improving, or deteriorating). Coagulation tests (PT, aPTT) and platelet counts may need to be observed and adjustments made in certain patients in order to decrease the risk of rebleeding.
Depending on the severity of the neurologic injury, patients may require physical therapy, occupational therapy, long-term rehabilitation, or even nursing-home placement.
Although CT imaging alone is usually sufficient for short-term management, a brain MRI is sometimes used (after a patient is stabilized) to look for associated brain injuries.
Serial imaging studies may be necessary to confirm that the acute SDH has fully resolved; a residual hematoma could become a symptomatic chronic SDH. This transformation can occur regardless of whether the hematoma has been managed surgically or conservatively.
Chronic subdural hematoma
As with acute SDH, serial neurological examinations are used and coagulation parameters may need to be followed. Serial CT scans are used to document the resolution of the chronic SDH.
Depending on the patient, physical therapy, occupational therapy, long-term rehabilitation, or even nursing home placement may be needed.
If the patient was on anticoagulation therapy preoperatively, when to restart anticoagulation therapy is complicated. No solution is perfect. The risks and benefits of anticoagulation must be weighed against the risks of rebleeding to determine when to restart therapy.
Complications
Acute subdural hematoma
As mentioned above, parenchymal brain injury is commonly associated with acute subdural hematoma (SDH) and can lead to increased ICP. Residual neurologic problems, as well as secondary events, can result from these associated injuries.
As with every medical condition and treatment, inherent risks exist. Postoperatively, recurrent or residual hematoma might be present, which, if symptomatic, may require repeat operative intervention. As many as one third of patients experience posttraumatic seizures after a severe head injury. Wound infection and CSF leak are possible after craniotomy. Meningitis or cerebral abscess can occur after any intracranial procedure, and constitutional signs of infection, delayed neurological deterioration, or signs of meningeal irritation may require further evaluation.
A long list of potential complications may also be related to anesthesia and hospitalization.
Chronic subdural hematoma
Among patients with chronic SDH who underwent surgical drainage, 5.4-19% experienced medical or surgical complications. Medical complications, including seizures, pneumonia, empyema, and other infections, occurred in 16.9% of cases. Surgical complications, including acute SDH formation, intraparenchymal hematoma, or tension pneumocephalus, occurred in 2.3% of cases.
After surgery for SDH, even with normalization of ICP, a persistent space may exist between the brain and dura, since the brain may not expand to fill this space. Residual hematoma has been found on 92% of postoperative CT scans within 4 days of operation; however, clinical improvement may proceed regardless of the size of this collection.
Reoperation rates for reaccumulation of hematoma have been reported to be from 12-22%. When the reoperation for burr-hole drainage was compared with craniotomy drainage, similar rates of 18.5% and 12.5% were found. However, the total number of craniotomies performed in this series was small. Of the patients who require a second operation to drain a reaccumulated hematoma, 26.6% (a total of 4 patients) required a third procedure to drain reaccumulated hematoma. Two of these 4 patients who underwent 3 operations developed subdural empyema. In another series, contralateral hematomas formed in 4% of patients who underwent drainage of unilateral chronic SDHs. These occurred from 3 days to 6 weeks postoperatively.19
Postoperative seizures have been reported in 3-10% of patients. Whether prophylactic anticonvulsants therapy can decrease this risk is debatable. Subdural empyema, brain abscess, and meningitis have been reported to occur in less than 1% of patients after operative drainage of a chronic SDH. In these patients, numerous potential complications are also related to anesthesia, hospitalization, patient age, and concurrent medical conditions.
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| Workup: Subdural Hematoma |
 Treatment: Subdural Hematoma |
| Follow-up: Subdural Hematoma |
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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.
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
