Emergent Management of Acute Subdural Hematoma 

Because acute subdural hematoma (SDH) is not only the most common type of intracranial mass lesion, occurring in about one third of those with severe head injuries (Glasgow Coma Scale [GCS] score < 9), but also associated with high mortality and morbidity rates, the emergent management of acute subdural hematoma (SDH) is critical.

An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoid membrane (see the first image below). Two further stages, subacute and chronic, may develop with untreated acute subdural hematoma (SDH). Generally, the subacute phase begins 3-7 days after acute injury (surgical literature favors 3d; radiologic literature favors 7d) (see the second image below). The chronic phase begins about 2-3 weeks after acute injury.

See also Subdural Hematoma, Subdural Hematoma Surgery, Imaging in Subdural Hematoma, Closed Head Trauma, Head Injury, and Forensic Autopsy of Blunt Force Trauma.

Consultation and/or transfer

Consult a neurosurgeon as soon as the diagnosis of subdural hematoma (SDH) is suspected.

Initiate rapid transfer if another facility is required for diagnosis or management: Rapid transport to a trauma center with a promptly available neurosurgeon decreases mortality in patients with subdural hematoma (SDH).^[1] Transfer may be emergent, with appropriate stabilization measures taken and with appropriately skilled personnel accompanying the patient.

Intubation and imaging

Consider endotracheal intubation when Glasgow Coma Score (GCS) score is less than 12 or other indications are present; this guarantees airway protection during the diagnostic workup.

Obtain an immediate head computed tomography (CT) scan in patients with head trauma who experienced clear loss of consciousness (LOC), are symptomatic, are disoriented/amnestic, or have any focal neurologic signs. The presence of a focal neurologic sign following blunt head trauma is ominous.

Optimizing venous outflow and reducing ICP

Elevate the head of the bed to 30°, and make sure that the head and neck are maintained in a midline position to optimize venous outflow from the brain.

Hyperventilation to a target partial pressure of carbon dioxide (pCO₂) of 30 mm Hg can reduce intracranial pressure (ICP) in the short term, although a pCO₂ level less than 25 mm Hg is strongly discouraged.

Intravenous mannitol (0.25 g/kg) may be used to decrease ICP. However, glucocorticoids are not indicated for head trauma.

Hemostasis

In patients taking warfarin with traumatic intracranial hemorrhage (ICH), use of recombinant factor VIIa (rFVIIa) in the emergency department was associated with a decreased time to normal international normalized ratio (INR).^[2] However, no difference in mortality was identified.^[2] Use of rFVIIa in patients on warfarin requires further study to demonstrate improved clinical outcomes before being routinely incorporated into clinical care.

Trephination

Burr holes are a temporizing option when rapid demise is associated with severe head trauma, especially if a herniation syndrome is clinically evident.^[3] Generally, because the lesion represents clotted blood, the burr hole is not curative, and emergent craniotomy is necessary. However, Burr holes can guide surgical therapy when head CT imaging is unavailable. Begin on the side of the (first) dilated pupil.

When a patient who experienced head trauma presents with a Glasgow Coma Score (GCS) score less than 12, consider immediate neurosurgical consultation while stabilizing the patient and while diagnostic maneuvers are in progress.

Small, asymptomatic, acute subdural hematomas (SDHs) may be managed by observation, serial examinations, and serial computed tomography (CT) scanning.

Operative intervention is required for patients with focal findings, neurologic worsening, hematoma greater than 1 cm thick, midline displacement or shift greater than 5 mm, or increased intracranial or posterior fossa pressure.^[4]

The usual treatment for acute subdural hematoma (SDH) is craniotomy and evacuation by a neurosurgeon,^[5] who, after making a large cranial flap, opens the dura. Then, the clot is removed with suction, cup forceps, and/or irrigation. Bleeding sites are identified and controlled.