Although significant acute traumatic subdural hematoma requires surgical treatment, temporizing medical maneuvers can be used preoperatively 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.
Adequate respiration should be initially addressed and maintained to avoid hypoxia. 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. [38]
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). Hyperventilation may decrease cerebral blood flow, thereby causing cerebral ischemia.
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.
A patient with coagulopathy or a patient with an acute SDH who is receiving anticoagulant medication should be transfused with prothrombin complex concentrate, 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. Dabigatran can be reversed with idarucizumab, and other reversal agents for the novel anticoagulants are under investigation. In patients who are receiving therapeutic anticoagulation, the potential effects of reversing the anticoagulation need to be considered.
The use of other factors, such as recombinant activated factor VII (rFVIIa), is under investigation. With traumatic intracranial hemorrhage in patients taking warfarin, use of rFVIIa was associated with a decreased time to normal International Normalized Ratio (INR). However, no difference in mortality was identified. [39] Use of rFVIIa in patients on warfarin requires further study to demonstrate improved clinical outcomes before being routinely incorporated into clinical care.
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Acute right-sided subdural hematoma associated with significant midline shift (ie, subfalcine herniation) shown on CT scan.
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Bilateral chronic subdural hematomas shown on CT scan. Midline shift is absent because of bilateral mass effect. Subdural hematoma is bilateral in 20% of patients with chronic subdural hematoma.
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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.
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A left-sided acute subdural hematoma (SDH). Note the high signal density of acute blood and the (mild) midline shift of the ventricles.
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A left-sided chronic subdural hematoma (SDH). Note the effacement of the left lateral ventricle.
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Chronic subdural hematomas (SDHs) are commonly bilateral and have areas of acute bleeding, which result in heterogeneous densities. Note the lack of midline shift due to the presence of bilateral hematomas.
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An isodense subdural hematoma (SDH). Note that no sulcal markings are below the inner table of the skull on the right side. This hematoma has scattered areas of hyperdense, or acute, blood within it.
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Isodense subdural hematoma (SDH) as pictured with MRI. MRI can more readily reveal smaller SDHs, and, on MRI, the imaging of the blood products change characteristically over time.
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Atrophy of the brain, resulting in a space between the brain surface and the skull, increases the risk of subdural hematoma (SDH).
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An acute subdural hematoma (SDH) as a complication of a craniotomy. Note the significant mass effect with midline shift.
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Acute subdural hematoma. Note the bright (white) image properties of the blood on this noncontrast cranial CT scan. Note also the midline shift. Image courtesy of J. Stephen Huff, MD
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Subacute subdural hematoma. The crescent-shaped clot is less white than on CT scan of acute subdural hematoma. In spite of the large clot volume, this patient was awake and ambulatory. Image courtesy of J. Stephen Huff, MD.
