Treatment of acute subdural hematoma.

OPINION STATEMENT: Clinical presentation, neurologic condition, and imaging findings are the key components in establishing a treatment plan for acute SDH. Location and size of the SDH and presence of midline shift can rapidly be determined by computed tomography of the head. Immediate laboratory work up must include PT, PTT, INR, and platelet count. Presence of a coagulopathy or bleeding diathesis requires immediate reversal and treatment with the appropriate agent(s), in order to lessen the risk of hematoma expansion. Reversal protocols used are similar to those for intracerebral hemorrhage, with institutional variations. Immediate neurosurgical evaluation is sought in order to determine whether the SDH warrants surgical evacuation. Urgent or emergent surgical evacuation of a SDH is largely influenced by neurologic examination, imaging characteristics, and presence of mass effect or elevated intracranial pressure. Generally, evacuation of an acute SDH is recommended if the clot thickness exceeds 10 mm or the midline shift is greater than 5 mm, regardless of the neurologic condition. In patients with patients with an acute SDH with clot thickness <10 mm and midline shift <5 mm, specific considerations of neurologic findings and clinical circumstances will be of importance. In addition, consideration will be given as to whether an individual patient is likely to benefit from surgery. For an acute SDH, evacuation by craniotomy or craniectomy is preferred over burr holes based on available data. Postoperative care includes monitoring of resolution of pneumocephalus, mobilization and drain removal, and monitoring for signs of SDH reaccumulation. Medical considerations include seizure prophylaxis and management as well as management and resumption of antithrombotic and anticoagulant medication.