Diagnosis and management of subdural hematoma: a review of recent literature

Wed Alshora, Mohammed Alfageeh, Salman Alshahrani, Saeed Alqahtani, Abdulrahman Dajam, Mutaz Matar, Rakan Ashour, Atif Alasmari, Abdulrhman Alqhtani


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.


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

Full Text:



Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States veterans administration and civilian populations. J Neurosurg. 2015;123(5):1209–15.

Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N. Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect. Neurol Med Chir (Tokyo). 1992;32(4):207–9.

Talvik I, Metsvaht T, Leito K, Põder H, Kool P, Väli M, et al. Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia. Acta Paediatr. 2006;95(7):799–804.

Tanikawa M, Mase M, Yamada K, Yamashita N, Matsumoto T, Banno T, et al. Surgical treatment of chronic subdural hematoma based on intrahematomal membrane structure on MRI. Acta Neurochir. 2001;143(6):613–8.

Lee JY, Ebel H, Ernestus RI, Klug N. Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol. 2004;61(6):523–7.

Maxeiner H, Wolff M. Pure subdural hematomas: a postmortem analysis of their form and bleeding points. Neurosurgery. 2002;50(3):503–8.

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of acute subdural hematomas. Surgical Management of Traumatic Brain Injury Author Group. Neurosurgery. 2006;58(3):16–24.

Smith MD, Kishikova L, Norris JM. Surgical management of chronic subdural haematoma: one hole or two? Int J Surg. 2012;10(9):450–2.

Rajajee V, Riggs B, Seder DB. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care. 2017;27(1):4–28.

Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252(6):959–65.

Badri S, Chen J, Barber J, Temkin NR, Dikmen SS, Chesnut RM. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med. 2012;38(11):1800–9.

Mayer SA, Chong JY. Critical care management of increased intracranial pressure. J Int Care Med. 2002;17(2):55–67.

Muizelaar JP,Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. 1991;75(5):731–9.

Andrews PJ, Sinclair HL, Rodriguez A, Harris BA, Battison CG, Rhodes JK, et al. Eurotherm3235 trial collaborators. Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med. 2015;373(25):2403–12.

Gaist D, García Rodríguez LA, Hellfritzsch M, Poulsen FR, Halle B, Hallas J, et al. Association of antithrombotic drug use with subdural hematoma risk. JAMA. 2017;317(8):836–46.

Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6-46.

Desborough MJ, Oakland KA, Landoni G, CrivellariM, Doree C, Estcourt LJ, et al. Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost. 2017;15(2):263-72.

Allard CB, Scarpelini S, Rhind SG, Baker AJ, Shek PN, Tien H, et al. Abnormal coagulation tests are associated with progression of traumatic intracranial hemorrhage. J Trauma. 2009;67(5):959–67.

Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ. Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6):71–109.

Rabinstein AA, Chung SY, Rudzinski LA, Lanzino G. Seizures after evacuation of subdural hematomas: incidence, risk factors, and functional impact. J Neurosurg. 2010;112(2):455–60.

Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery. 2017;80(1):6–15.

Inaba K, Menaker J, Branco BC, Gooch J, Okoye OT, Herrold J, et al. A prospective multicenter comparison of levetiracetam versus phenytoin for early posttraumatic seizure prophylaxis. J Trauma Acute Care Surg. 2013;74(3):766–71.

Won SY, Dubinski D, Bruder M, Cattani A, Seifert V, Konczalla J. Acute subdural hematoma in patients on oral anticoagulant therapy:management and outcome. Neurosurg Focus. 2017;43(5):12.

Rand BO, Ward AA Jr, White LE Jr. The use of the twist drill to evaluate head trauma. J Neurosurg. 1966;25(4):410–5.

Caron JL, Worthington C, Bertrand G. Tension pneumocephalus after evacuation of chronic subdural hematoma and subsequent treatment with continuous lumbar subarachnoid infusion and craniostomy drainage. Neurosurgery. 1985;16(1):107–10.

Asfora WT, Schwebach L. Amodified technique to treat chronic and subacute subdural hematoma: technical note. Surg Neurol. 2003;59(4):329–32.

Neal MT, Hsu W, Urban JE, Angelo NM, Sweasey TA, Branch CL Jr. The subdural evacuation port system: outcomes from a single institution experience and predictors of success. Clin Neurol Neurosurg. 2013;115(6):658–64.

Krieg SM, Aldinger F, Stoffel M, Meyer B, Kreutzer J. Minimally invasive decompression of chronic subdural haematomas using hollow screws: efficacy and safety in a consecutive series of 320 cases. Acta Neurochir. 2012;154(4):699–705.

Yadav YR, Yadav S, Parihar VS. Modified twist drill technique in the management of chronic subdural hematoma. Turk Neurosurg. 2013;23(1):50–4.

Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013;35(3):233–42.

Wang QF, Cheng C, You C. A new modified twist drill craniostomy using a novel device to evacuate chronic subdural hematoma. Medicine (Baltimore). 2016;95(10):e3036.

Lu J, Shen D, Hu F, Zhou J, Lan F, Guo D, et al. An improved electronic twist-drill craniostomy procedure with post-operative urokinase instillation in treating chronic subdural hematoma. Clin Neurol Neurosurg. 2015;136:61–5.

Khadka NK, Sharma GR, Roka YB, Kumar P, Bista P, Adhikari D, et al. Single burr hole drainage for chronic subdural haematoma. Nepal Med Coll J. 2008;10(4):254–7.

Taussky P, Fandino J, Landolt H. Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma. Br J Neurosurg. 2008;22(2):279–82.

Gazzeri R, GalarzaM, NeroniM, Canova A, Refice GM, Esposito S. Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma. Acta Neurochir. 2007;149(5):487–93.

Singh AK, Suryanarayanan B, Choudhary A, Prasad A, Singh S, Gupta LN. A prospective randomized study of use of drain versus no drain after burr-hole evacuation of chronic subdural hematoma. Neurol India. 2014;62(2):169–74.

Kutty SA, Johny M. Chronic subdural hematoma: a comparison of recurrence rates following burr-hole craniostomy with and without drains. Turk Neurosurg. 2014;24(4):494–7.

Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery. 2009;64(6):1116–21.

Servadei F, NasiMT, Cremonini AM, Giuliani G, Cenni P, Nanni A. Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: a prospective study of 65 patients. J Trauma. 1998;44(5):868-73.

Koç RK, Akdemir H, Oktem IS, Meral M, Menkü A. Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev. 1997;20(4):239–44.