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Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas

  • Critical Care Neurology (K Sheth, Section Editor)
  • Published:
Current Treatment Options in Neurology Aims and scope Submit manuscript

Abstract

Purpose of review

Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative.

Recent findings

While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy.

Summary

Surgical SDH management is variable depending on its characteristics and etiology, patient’s functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.

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Acknowledgements

The editors would like to thank Dr. Myrna Rosenfeld for taking the time to review this manuscript.

Funding

Elena I Fomchenko, Charles C Matouk, and Jason L Gerrard are supported by Yale Neurosurgery. Emily J Gilmore and Kevin N Sheth are supported by Yale Department of Clinical Neurosciences.

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Authors and Affiliations

  1. Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA

    Elena I. Fomchenko MD, PhD, Charles C. Matouk MD & Jason L. Gerrard MD

  2. Department of Neurology, Yale University School of Medicine, New Haven, CT, USA

    Emily J. Gilmore MD & Kevin N. Sheth MD

  3. Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA

    Emily J. Gilmore MD & Kevin N. Sheth MD

  4. Department of Clinical Neurosciences, Yale University, 20 York St, New Haven, CT, USA

    Kevin N. Sheth MD

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  1. Elena I. Fomchenko MD, PhD
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  2. Emily J. Gilmore MD
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  3. Charles C. Matouk MD
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  4. Jason L. Gerrard MD
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Correspondence to Elena I. Fomchenko MD, PhD.

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Elena I Fomchenko, Emily J Gilmore, Charles C Matouk, and Jason L Gerrard each declare no conflict of interest. Kevin N Sheth is a section editor for Current Treatment Options in Neurology.

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Fomchenko, E.I., Gilmore, E.J., Matouk, C.C. et al. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol 20, 34 (2018). https://doi.org/10.1007/s11940-018-0518-1

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