Surgical Management of Traumatic Acute Subdural Hematoma in Adults: A Review

Abstract

Traumatic acute subdural hematoma (ASDH) is a major clinical entity in traumatic brain injury (TBI). It acts as a space occupying lesion to increase intracranial pressure, and is often complicated by co-existing lesions, and is modified by cerebral blood flow (CBF) changes, coagulopathy, and delayed hematomas. Because of its complicated pathophysiology, the mortality of ASDH is still remaining high. In this review article, its epidemiology, pathophyiology, surgical treatment, and salvage ability are described. With regard to epidemiology, as the population ages, growing number of elderly patients with ASDH, especially patients with prehospital anticoagulant and antiplatelets, increase. Concerning pathophysiology, in addition to well-known initial intracranial hypertension and subsequent ischemia, delayed hyperemia/hyperperfusion, or delayed hematoma is being recognized frequently in recent years. However, optimal treatments for these delayed phenomenons have not been established yet. With regard to surgical procedures, all of craniotomy, decompressive craniectomy, and initial trephination strategies seem to be effective, but superiority of each procedure have not been established yet. Since Glasgow Coma Scale (GCS) scores, age, papillary reaction, and computed tomographic findings are strongly correlated to outcome, each factor has been investigated as an indicator of salvage ability. None of them, however, has been defined as such one. In future studies, epidemiological changes as population ages, management of delayed pathophysiology, superiority of each surgical procedures, and salvage ability should be addressed.

Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis

“…Parenchymal herniation during the operation of patients with more significant injuries may prevent replacement of the bone flap. 3 The operating neurosurgeon may have been attempting to perform a craniotomy but due to technical reasons was unable to replace the bone. This is confounding by indication and occurs when variables associated with the outcome in the reference population, are also associated with the exposure.…”

“…1 Of those patients with a TBI, the frequency of acute subdural hemorrhage (ASDH) in patients is between 10–30%. 3–5 Furthermore, patients with ASDH often present with intracranial hypertension or neurologic dysfunction that requires emergent surgical decompression. 3 At the time of surgery, provided there is no extracranial herniation, it often remains unclear if the bone flap should be removed (decompressive craniectomy, DC) or replaced (craniotomy).…”

“…3–5 Furthermore, patients with ASDH often present with intracranial hypertension or neurologic dysfunction that requires emergent surgical decompression. 3 At the time of surgery, provided there is no extracranial herniation, it often remains unclear if the bone flap should be removed (decompressive craniectomy, DC) or replaced (craniotomy). There is wide variation in the clinical practice of neurosurgeons around the world.…”

Leakage sign for acute subdural hematoma in clinical treatment

“…Contrarily, some patients with a small hematoma and faint disturbance of consciousness on admission show a delayed, sudden increase in hematoma size, whereas other cases show no increase in hematoma size, resulting in good outcomes. Thus, the timing and decision of surgical intervention is an important issue for ASDH patients [5, 6, 14]. Correctly predicting the expansion of the hematoma is crucial.…”

Radiologic Findings and Patient Factors Associated with 30-Day Mortality after Surgical Evacuation of Subdural Hematoma in Patients Less Than 65 Years Old

“…Traumatic acute subdural hematoma (SDH) is a common condition confronting neurosurgeons, and it is reported that the percentage of acute SDH in patients admitted with a traumatic brain injury (TBI) is approximately 10–20%16,24). A previous study reported that approximately 60% of severe TBI patients have acute SDH to various extents.…”