Traumatic Acute Subdural Hematoma

Items:

Strength of Recommendation

Level of Evidence

-  Avoid hypoxia

Strong

Moderate-Quality Evidence⁵

-  Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2

Strong

Moderate-Quality Evidence⁵

-  Avoid hypotension

Strong

Moderate-Quality Evidence⁵

- Brain imaging (CT) must be available and repeated if needed. we recommend also ICU admission, close neurosurgical observation (if any of them not available, refer to a tertiary center). 

Strong

High-Quality Evidence⁶

·  The availability of equipped neurosurgery operating room is essential for management (if it is not available, refer to a tertiary center).

Strong

High-Quality Evidence⁶

·       Antiseizure medications (ASM):

Consider the use of ASMs (e.g., phenytoin, valproate, or carbamazepine) to decrease the incidence of early PTS (within 7 days of TBI).

Conditional

Moderate-Quality Evidence⁵

Level of recommendation

Level of evidence

-  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 as soon as possible, guided by the patient’s Glasgow Coma Scale (GCS) score.

Conditional

Intermediate certainty evidence.⁷

-  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 as soon as possible, if the patient develops one or more of the following criteria:

-  A sustained decrease of the GCS score by 2 or more points from that measured at the time of first assessment that is refractory to conservative management (after exclusion of general causes).

-  Signs of lateralization.

-  Increased intracranial pressure (ICP).

Conditional

Intermediate certainty evidence⁷

- If surgical evacuation of an acute SDH is indicated, it should be performed using a traumatic flap craniotomy/craniectomy preferable with duraplasty.

Good practice statement

Intermediate certainty⁷ evidence