Subdural hematoma

Subdural hematoma (SDH) has a variable disease course, depending on size of hematoma, age of the patient, presenting neurologic signs/symptoms, presence of underlying coagulopathy or neoplasm, and associated injuries.

One week of prophylactic anticonvulsants (e.g., phenytoin, levetiracetam) should be considered in all cases of acute and acute-on-chronic SDH, according to the Brain Trauma Foundation guidelines.

Tailored management and reversal of antithrombotic therapy is a key element of initial care for all patients with SDH.

The choice between surgery or conservative management for SDH is typically based on hematoma size, extent of midline shift, severity of neurologic dysfunction and degree of elevated intracranial pressure (ICP). The degree of surgical risk and potential for recovery may also be considered.

Observation may be employed for small, stable SDHs that are not causing neurologic compromise.

Control of elevated ICP using head-of-bed elevation, analgesics, intubation with anesthetics and sedation, hyperosmolar treatment, barbiturates, or decompressive hemicraniectomy may be required.

Treatment complications include early or delayed reaccumulation of SDH, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the hematoma, strokes, persistent neurologic deficit, coma, and death.

SDH is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the hematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of SDH can be inferred by neurologic decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (computed tomography or magnetic resonance imaging).