International Journal of Community Medicine and Public Health

Alshora W et al. Int J Community Med Public Health. 2018 Sep;5(9):xxx-xxx

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20183440
Review Article

Diagnosis and management of subdural hematoma: a review

of recent literature
Wed Alshora1*, Mohammed Alfageeh2, Salman Alshahrani3, Saeed Alqahtani3,
Abdulrahman Dajam3, Mutaz Matar4, Rakan Ashour5, Atif Alasmari3, Abdulrhman Alqhtani3

1
Cairo University, Cairo, Egypt
2
Faculty of Surgery, Umm Al-Qura University, Al Qunfudhah, KSA
3
King Khalid University, Abha, KSA
4
Umm Al-Qura University, Mecca, KSA
5
Al Noor Hospital, Mecca, KSA

Received: 22 July 2018

Accepted: 10 August 2018

*Correspondence:
Dr. Wed Alshora,
E-mail: wedalsh@hotmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Subdural hematoma is extra-cerebral accumulation of blood between the dura matter and the subarachnoid layer.
Subdural hematoma can be associated with significant long-term morbidities and high rates of mortality. The
mortality following subdural hematoma can be as high as 32%, and recurrence rates can reach 33%. Acute subdural
hematoma is an emergency and requires prompt diagnosis using CT most of the time, and management requires
surgery as well as reversal of anticoagulants. We conducted this review using a comprehensive search of MEDLINE,
PubMed, and EMBASE, January 1985, through February 2017. The following search terms were used: emergency
management of subdural hematoma, subdural hematoma, CT vs. MRI in diagnosis of subdural hematoma, treatment
of subdural hematoma. In this review, our aim is to study the etiology of subdural hematoma and understand how it
should be diagnosed and managed. Subdural hematoma are clinical emergencies that require immediate and rapid
management to prevent significant morbidity and mortality. They can be grouped into acute, subacute, or chronic,
with the acute type being the most dangerous and associated with the highest mortality rates. Subdural hematoma is
diagnosed using CT or MRI imaging. Management of a patient with subdural hematoma includes resuscitation
followed by control of the bleeding. Controlling intracranial pressure is an important factor for predicting the
outcomes of subdural hematoma, and should thus be continuously monitored and corrected.

Keywords: Subdural hematoma, Diagnosis in emergency room for subdural hematoma, CT vs. MRI, Management of
subdural hematoma

INTRODUCTION than females, and it is estimated that about 20% of

subdural hematomas in males are bilateral at
Subdural hematomas are relatively commonly presentation.2 Although incidence in younger populations
encountered cases that always face neurosurgeons. is less than older populations, infants and toddlers have a
Incidence and prevalence of subdural hematomas have relatively higher incidence when they are compared to
been increasing lately, with this increase being more other age groups, with an incidence that can reach 40 per
prominent in older individuals that could reach 80 cases 100,000 person-years. Etiologies of these cases in infants
per 100,000 person-years.1 Generally, males have a and toddlers could be attributed to causes different than
higher incidence and prevalence of subdural hematomas other age groups. These etiologies could include

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hydrocephalus, trauma during birth, hematologic The study was approved by the review board of King
diseases, genetic diseases, infections and sepsis, and AbdulAziz Hospital.
vascular malformations.3
Initial management of SDH patients
Subdural hematoma can be associated with significant
long-term morbidities and high rates of mortality. In fact, When dealing with either acute, subacute, or chronic
it is estimated that mortality following subdural subdural hematoma, management must start with
hematoma can be as high as 32%, and recurrence rates applying advanced trauma life support protocols. In the
can reach 33%. Moreover, in cases of traumatic acute recent guidelines, the Neuro-Critical Care Society
subdural hematoma, mortality can reach 90% in some recommend maintaining a mean arterial pressure between
clinical settings. Glasgow coma scale has been found to 80 and 110 mmHg, with a systolic arterial pressure that
be inversely related with mortality rates.4 does not exceed 180 mmHg. These targets aim at the
maintenance of a sufficient cerebral perfusion with the
Subdural hematomas originate from the inner layer of the prevention of continuous hemorrhage.8 Oxygenation of
dura, and out of the arachnoid resulting in multiple the brain must be kept at 60 mmHg, as hypoxia can lead
septations that contain blood. This nature of subdural to significant permanent damage.9 In some cases of
hematoma make its management quite challenging and severe injuries, agitation, intoxication, or altered mental
lead to high recurrence rates.5 There are many factors that status, intubation is administrated to achieve sufficient
aid the expansion of subdural hematomas. These include oxygenation and to decrease aspiration risk.10 To provide
the recurrence of bleeding that could be due to elevated sufficient sedation in trauma settings, etomidate is usually
levels of fibrinogen and plasmin, the liquefaction of used for induction along with propofol, ketamine, and
subdural hematomas leading to an osmotic gradient and fentanyl. Intravenous lidocaine is also usually
an enlarging subdural hematoma compartment, and the administrated to prevent elevated intracranial pressure. 9
inflammatory process that is associated with To achieve sufficient neuromuscular blockade,
neovascularization leading to more bleeding.5 intravenous succinylcholine, rocuronium, or
cisatracurium could be used.9 After intubation is
Subdural hematomas are categorized into acute, subacute, achieved, sedatives that are used to maintain the sedation
and chronic. Acute subdural hematoma presents within 3 status include propofol, midazolam, fentanyl,
days of the bleeding, subacute subdural hematoma dexmedetomidine, or remifentanil.
presents within four to twenty days of the bleeding, and
chronic subdural hematoma presents any time after Imaging to confirm the diagnosis
twenty days of the bleeding. The diagnostic methods of
choice for the diagnosis of subdural hematomas are CT or After achieving sufficient resuscitation of the patient,
MRI imaging techniques. Most acute subdural hematoma intracranial imaging is required to confirm the diagnosis
cases can be attributed to venous bleeding following of subdural hematoma and plan proper management. The
traumatic rupture of bridging veins, and leading to use of CT scan imaging in the detection of subdural
increased intracranial pressure. About 20% of acute hematoma has several advantages including the wide
subdural hematoma cases can be due to an arterial availability, rapid results, and high sensitivity and
rupture.6 specificity, which can reach 96% and 98% respectively.
On the other hand, MRI imaging techniques are still
When dealing with patients who suffer from a traumatic preferred due to sensitivity and specificity that reach
brain injury, the prevalence of subdural hematomas can 100%, the ability to detect even minimal bleeding, and
reach 20%, with about half of these patients presenting in the ability to identify etiologies.
a coma.7 On the other hand, the use of antiplatelet and
anticoagulation drugs can also lead to the formation of a Both CT and MRI imaging techniques can give
subdural hematoma.7 However, infantile subdural information on the size of the hematoma, chronicity of
hematoma has not been well understood yet. the bleeding, medline shifting (if present), effacement of
basal cistern, and trapping of the ventricles. When the
METHODS etiology is suspected to be of vascular origins, patients
are recommended to further undergo MRA. Emergent
We did a systematic search for subdural hematoma using imaging is indicated in any case that shows dramatic
PubMed search engine (http://www.ncbi.nlm.nih.gov/) deterioration of clinical or mental status.6
and Google Scholar search engine (https://scholar.
google.com). Our search also looked for the prevalence, Management of intracranial hypertension in subdural
etiologies, diagnosis, and treatment of subdural hematoma
hematoma cases. All relevant studies were retrieved and
discussed. We only included full articles. The following Usually, subdural hematoma is associated with a
search terms were used: emergency management of significant increase in intracranial pressure.
subdural hematoma, subdural hematoma, CT vs. MRI in Unfortunately, an intracranial pressure that is higher than
diagnosis of subdural hematoma, treatment of subdural 22 has been associated with worse survival outcomes,
hematoma. and higher morbidity and mortality in patients who

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present with subdural hemorrhage.11 Therefore, patients who have subdural hematoma due to a traumatic
management of increased intracranial pressure is of brain injury can have severe coagulopathy. This can even
extreme importance in subdural hematomas. Initially, lead to the development of disseminated intravascular
simple measures like head elevation could be applied. coagulation (DIC). Management of disseminated
These will help in preventing obstruction of venous intravascular coagulation include coagulation factors,
outflow.12 Another important measure is hyperventilation cryoprecipitate, and prothrombin complex concentrate
that will lead to vasoconstriction and a decrease in transfusion.18
intracranial pressure.11 However, long-term hyper-
ventilation has been associated with ischemia and The return to anticoagulation agents use is still a
alkalosis, therefore it should be cautiously used. In fact, a controversial issue. The American College of Chest
clinical trial has shown that applying hyperventilation in Physicians recommend the discussion of anticoagulants
patients with traumatic brain injury for five days was resumption on a case basis, with taking into consideration
associated with worse outcomes.13 Hypertonic saline and the severity of hematoma, risk of subdural hematoma
hyperosmotic saline could also be beneficial as they recurrence, and risk of thrombosis.19
promote the shift of fluids into the circulation and out of
cerebral intracellular compartments. However, there use Management of seizures in subdural hematoma
should be temporary. The placement of a shunt that will
drain CSF is not recommended due to the risk of Prophylaxis against seizures is still an area of debate in
stretching veins. Several factors can aid in determining subdural hematoma cases. Previous reports have
the use of hyperosmolar saline versus hypertonic saline. suggested that up to 25% of patients with traumatic
These include volume status, history and comorbidities. subdural hematoma will develop seizures at least once
For example, if the patient is hypotensive, hypertonic through their clinical course.20 Recent guidelines have
therapy is preferred. On the other hand, patients who recommended the use of phenytoin as a prophylaxis of
have a history of congestive heart failure are seizures in patients who present with a traumatic subdural
recommended to take mannitol. High sodium levels hematoma.21 Seizures can be associated with poor
(more than 165 mEq/L) have also been associated with outcomes due to their effects in increasing metabolism
poor prognosis. However, correcting sodium levels has and elevating intracranial pressure.20 More recently, the
not been found to improve outcomes, or decrease use of levetiracetam in seizures prophylaxis for subdural
intracranial pressure.14 Hypothermia could also have an hematoma patients has been increasing.22
effect in lowering intracranial pressure and improving
outcomes of subdural hematoma. However, this effects is However, when dealing with elderly patients with chronic
still studied in clinical trials with no clear evidence to subdural hematoma, no evidence is present to support the
support this.14 Moreover, hypothermia could potentially use of anti-seizures prophylaxis. Won et al suggested the
lead to other complications like arrhythmias.14 use of a scoring system in this population to assess their
risk of seizures and thus their need of prophylactic
Antiplatelet and anticoagulation agents and subdural therapy. This score takes several factors into
hematoma consideration including the use of anticoagulation drugs,
the need for surgery, the presence of seizures history,
The use of antiplatelet and anticoagulation agents is along with other factors.23
widely prevalent which led to significant increase in the
incidence of spontaneous subdural hematomas. These In conclusion, continuous research on anti-seizures drugs
cases of subdural hematoma can sometimes be difficult to and their use in subdural hematoma is still required to
reverse.15 To achieve better outcomes in these cases, establish their use for different presentations and
rapid reversal of anticoagulation is essential.16 Patients scenarios.
who are on warfarin and who develop a spontaneous
subdural hemorrhage should immediately receive vitamin Indication for surgical interventions
K and prothrombin complex concentrate, with INR being
continuously monitored. In severe emergency cases, As mentioned above, asymptomatic and mild cases of
recombinant factor VIIa could also be used.17 subdural hematoma can be treated medically. However,
in moderate to severe cases, or when clinical
When dealing with spontaneous subdural hematoma in deterioration is present, surgical intervention is indicated.
patients who are on dabigatran, apixaban, rivaroxaban, or Recurrent subdural hematomas can also be an indication
edoxaban, the use of the monoclonal antibody for surgical intervention. A recurrent subdural hematoma
idarucizumab is recommended. Other options in this is defined as the re-accumulation of the bleeding that
population include plasmapheresis and hemodialysis.16 becomes symptomatic again. Altered mental status,
The use of platelet transfusions in this specific population dilatation of both pupils, or extensor posturing are also
has been found to cause higher mortality rates.16 alarming signs that require immediate surgical
intervention. As a general rule, subdural hematomas that
The presence of coagulopathy is not limited to are larger than 10 mm can be considered for surgical
spontaneous subdural hematoma. About a third of intervention. There are several surgical techniques that

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are used in cases of subdural hematoma. These include The use of tPA during and after twist drill craniostomy
twist drill craniostomy, burr hole(s), craniotomy, along has also been associated with better outcomes. A
with other procedures that we will discuss.4 previous trial has found that recurrence rates can be
lowered to zero when using tPA. The use of urokinase
Twist drill craniostomy procedure for the treatment of has also been associated with better outcomes, shorter
subdural hematoma hospital stays, and recurrence rates that are as low as
0.4%.32
The twist drill craniostomy procedure for the treatment of
subdural hematoma was first introduced in 1966. 24 Over Burr hole evacuation for the treatment of subdural
time, the procedure have improved significantly with the hematoma
introduction of newer more advanced techniques, and
with more profound studying of ideal drilling angles, The burr hole evacuation technique is considered to be
points to enter, drilling methods, use of screws, and one of the most common and widely used procedures in
irrigation ports. Moreover, the twist drill craniostomy the surgical treatment of subdural hematoma. To perform
procedure has been associated with relatively low rate of a burr hole evacuation, an environment that achieves all
complications when compared to other surgical conditions of surgical operation is required. Usually, the
interventions. Despite being low, these complications can burr hole measures about 14mm allowing for a good
include seizures, infections, and subdural hematoma visualization of the hematoma, the detection of clots (if
recurrence. Severs complications like pneumocephalus present), faster access and control of the hemorrhage, and
are very rare.25 the ability to use other additional surgical instruments
like endoscopes, which are not achievable in twist drill
The SEPS technique was later described in 1999 and led craniostomy.33
to significantly better outcomes with even lower
complications and recurrence rates. In this procedure, a Burr hole evacuation is available both under local or
port with threads are entered the thick portion of the general anesthesia. It has been estimated that burr hole
subdural hematoma without going into the subdural space evacuation under local anesthesia could achieve 98.6%
itself. Application of this allows drainage slowly with the evacuation with a recurrent rate that is 4.7%.33 The use of
concepts of negative pressure.26 It was estimated that single versus multiple holes when performing a burr hole
SEPS procedure has a success rate that can reach 77%. evacuation procedure has also been studied. It was
However, this success rate is lower in patients who have reported that multiple burr holes were associated with
septated or mixed density subdural hematomas.27 In significantly less recurrent rates.34
SEPS technique, it was found that head elevation degree
is not associated with changes in drainage or recurrence The most important factor to determine success rates
risk. Some studies have suggested that following SEPS, following a burr hole procedure is the replacement of
up to 20% may need to further undergo burr holes drain. Drain replacement, actually, was found to lead to
procedure.28 significantly lower recurrence rates when compared to
burr hole evacuation procedure without drain. 35
When performing twist drill craniostomy on elderly Complications and mortality rates following the
patients with subdural hematoma, local anesthesia could procedure were not found to significantly differ with or
offer a better option, especially in patients who have without drain replacement.36 Moreover, the placement of
other comorbidities. To avoid the occurrence of damage a drain even in a single burr hole procedure was
to the cerebral parenchyma, a previous study has associated with improved outcomes and lower recurrence
suggested the use an infant feeding tube while draining rates when compared to multiple burr holes procedure.37
the hemorrhage.29 Generally, the twist drill craniostomy
procedure has been found in several studies to be The time for which draining continues also seems to have
associated with faster recovery, shorter hospital stays, an effect. Previous studies have found that continuing
and less complications when compared with burr holes.30 drainage for a period longer than three days was
associated with significant decrease in recurrence rates.
Moreover, sites of entry and duration of drainage when The site of drain replacement could also play a role in
performing a twist drill craniostomy can play a determining outcomes, reducing the risk of seizures, and
significant role in the determination of outcomes. When leading to less infections. Moreover, the use of
entry is done on the thick portions of the subdural subperiosteal drain was associated with significantly
hematoma, efficacy of twist drill craniostomy has been lower rates of recurrence when compared to subdural
found to increase in efficacy. Other key factors include drains.38
the use of ports that will allow the injection of other
therapies directly into the cavity of the subdural Craniotomy in the management of acute subdural
hematoma. A more recent model of twist drill hematoma
craniostomy uses two ports for both drainage and
irrigation.31 Patients who present with an acute subdural hematoma
accompanied by thick clots are recommended to undergo

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craniotomy. Other cases in which craniotomy is 2. Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N.
recommended include chronic or subacute subdural Chronic subdural hematoma in elderly people:
hematoma where other surgical procedures have not been present status on Awaji Island and epidemiological
successful. Generally, acute subdural hematoma is prospect. Neurol Med Chir (Tokyo).
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with significantly high mortality rates. Therefore, surgical 3. Talvik I, Metsvaht T, Leito K, Põder H, Kool P,
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a relatively high mortality rates. Possible reasons behind 5. Lee JY, Ebel H, Ernestus RI, Klug N. Various
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parenchyma, autoregulation dysfunctions, altered mental and outcome in 172 patients: is membranectomy
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Funding: No funding sources prolonged hyperventilation in patients with severe
Conflict of interest: None declared head injury: a randomized clinical trial. J
Ethical approval: Not required Neurosurg. 1991;75(5):731–9.
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