Traumatic Acute Subdural Hematoma

These guidelines are concerned with management of traumatic acute subdural hemorrhage.

Recommendations

Initial Management: (as a part of initial TBI management)

- Avoid hypoxia.

 Strong recommendation.

- 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 recommendation.

- Avoid hypotension.

Strong recommendation.

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

 Strong recommendation. 

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

 Strong recommendation.

- Anti-seizure 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 recommendation

➡️Definitive treatment

n 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

 Strong recommendation

- An acute 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).

 Strong recommendation

- If surgical evacuation of an acute SDH is indicated, it should be performed using a craniotomy/craniectomy ( preferably with duraplasty)

  Strong recommendation.