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

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          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.

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          Most cited references73

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          Surgical management of acute subdural hematomas.

          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, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. 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 of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible. If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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            The role of secondary brain injury in determining outcome from severe head injury.

            As triage and resuscitation protocols evolve, it is critical to determine the major extracranial variables influencing outcome in the setting of severe head injury. We prospectively studied the outcome from severe head injury (GCS score < or = 8) in 717 cases in the Traumatic Coma Data Bank. We investigated the impact on outcome of hypotension (SBP < 90 mm Hg) and hypoxia (Pao2 < or = 60 mm Hg or apnea or cyanosis in the field) as secondary brain insults, occurring from injury through resuscitation. Hypoxia and hypotension were independently associated with significant increases in morbidity and mortality from severe head injury. Hypotension was profoundly detrimental, occurring in 34.6% of these patients and associated with a 150% increase in mortality. The increased morbidity and mortality related to severe trauma to an extracranial organ system appeared primarily attributable to associated hypotension. Improvements in trauma care delivery over the past decade have not markedly altered the adverse influence of hypotension. Hypoxia and hypotension are common and detrimental secondary brain insults. Hypotension, particularly, is a major determinant of outcome from severe head injury. Resuscitation protocols for brain injured patients should assiduously avoid hypovolemic shock on an absolute basis.
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              Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours.

              To discover which factors contributed to recovery after surgical intracranial decompression, we reviewed the records of 82 consecutive comatose patients with traumatic acute subdural hematoma (ASDH) who were treated in a single center under a uniform protocol. The delay from injury to operation was the factor of greatest therapeutic importance. Patients who underwent surgery within the first four hours had a 30 per cent mortality rate, as compared with 90 percent in those who had surgery after four hours (P less than 0.0001). Other important prognostic variables included results of the initial neurologic examination, sex, multimodality-evoked potentials, and postoperative intracranial pressure (ICP). If all patients with traumatic ASDH were taken directly to hospitals equipped to diagnose and remove the hematoma within four hours of injury, mortality rates could be reduced considerably.
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                Author and article information

                Journal
                Neurol Med Chir (Tokyo)
                Neurol. Med. Chir. (Tokyo)
                NMC
                Neurologia medico-chirurgica
                The Japan Neurosurgical Society
                0470-8105
                1349-8029
                November 2014
                31 October 2014
                : 54
                : 11
                : 887-894
                Affiliations
                [1 ]Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi;
                [2 ]Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi
                Author notes
                Address reprint requests to: Hiroshi Karibe, MD, PhD, Department of Neurosurgery, Sendai City Hospital, 3-1, Shimizu-koji, Wakabayashi-ku, Sendai, Miyagi 980-8574, Japan. e-mail: karibe@ 123456nsg.med.tohoku.ac.jp

                Conflicts of Interest Disclosure

                The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices in the article. The authors who are members of the Japan Neurosurgical Society (JNS) have registered online Self-reported COI Disclosure Statement Forms through the website for JNS members.

                Article
                nmc-54-887
                10.2176/nmc.ra.2014-0204
                4533344
                25367584
                94e9991e-5fd6-45e3-94b1-c098385b67e3
                © 2014 The Japan Neurosurgical Society

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/

                History
                : 4 June 2014
                : 7 August 2014
                Categories
                Review Article

                acute subdural hematoma,traumatic brain injury,surgical management,indication,salvage ability

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