Surgical Management of Acute Subdural Hematomas

Abstract

RECOMMENDATIONS(see Methodology) Indications for Surgery • An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. • All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. • A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. Timing • In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible. Methods• If surgical evacuation of an acute SDH in a comatose patient (GCS Ͻ 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

Microbleeds as a Prognostic Factor for Acute Subdural Hematoma

“…Age, Glasgow Coma Scale score, and pupillary reactivity are known prognostic indicators in patients with acute SDH. 4,6) In some studies, SDH volume and midline brain shift have also been related to poor outcome. 4,9,14) This study is the first to report the effect of microbleeds on prognosis in patients with acute SDH.…”

“…4,6) In some studies, SDH volume and midline brain shift have also been related to poor outcome. 4,9,14) This study is the first to report the effect of microbleeds on prognosis in patients with acute SDH. Our results support a previous study that reported a relationship between microbleeds and prognosis in patients with moderate and severe traumatic brain injury and diffuse axonal injury.…”

“…4,12,13,18) The overall mortality rate in patients with acute SDH who require surgery is 40% to 60%. 4,13) Prognostic indicators of acute SDH are age, Glasgow Coma Scale score, pupillary reactivity, SDH volume, and midline brain shift.…”

“…4,12,13,18) The overall mortality rate in patients with acute SDH who require surgery is 40% to 60%. 4,13) Prognostic indicators of acute SDH are age, Glasgow Coma Scale score, pupillary reactivity, SDH volume, and midline brain shift. 4,6,9,14) Microbleeds identified on T 2 *-weighted magnetic resonance (MR) images correlate with outcome in patients with diffuse axonal injury.…”

“…4,13) Prognostic indicators of acute SDH are age, Glasgow Coma Scale score, pupillary reactivity, SDH volume, and midline brain shift. 4,6,9,14) Microbleeds identified on T 2 *-weighted magnetic resonance (MR) images correlate with outcome in patients with diffuse axonal injury. 7,16,20) However, the relationship between microbleeds and prognosis in patients with acute SDH is not known.…”