clinical deterioration not accounted for by findings on repeat head CT. Specific testing is determined by clinical features and patient risk factors. Seizures SDH may cause seizures due to compression of underlying cerebral cortex. Seizures may accompany acute SDH in the setting of mild or severe traumatic brain injury. (See "Posttraumatic seizures and epilepsy".) https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 12/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Patients with a persistent impairment in alertness not due to elevated ICP, those with fluctuating changes in neurologic examination, and those with witnessed convulsions warrant evaluation for seizures with electroencephalography. Ischemic stroke SDH may be complicated by ischemic stroke in patients with thromboembolic risk factors such as atrial fibrillation due to the reversal of anticoagulation to manage the SDH. In addition, ischemic stroke may infrequently occur in nonambulatory patients in the setting of embolization of a deep venous thrombosis. (See "Atrial septal abnormalities (PFO, ASD, and ASA) and risk of cerebral emboli in adults", section on 'Paradoxical emboli'.) Ischemic stroke should be suspected in at-risk patients with SDH who have a sudden clinical deterioration consistent with ischemic stroke ( table 5) and stable head CT. Brain magnetic resonance imaging (MRI) is the preferred imaging modality because acute ischemic stroke may not be visible on initial repeat head CT. The treatment of acute ischemic stroke is discussed separately. (See "Initial assessment and management of acute stroke".) Acute toxic-metabolic encephalopathy Patients with SDH may develop delirium due several causes including preexisting medical conditions, pain, or medications. The evaluation of patients with delirium is discussed separately. (See "Diagnosis of delirium and confusional states".) Evaluation for underlying causes Some patients with spontaneous SDH not associated with trauma or other obvious cause may warrant brain and/or vascular imaging and other testing to identify possible secondary causes. The evaluation of underlying causes of SDH is discussed separately. (See "Subdural hematoma in adults: Etiology, clinical features, and diagnosis", section on 'Evaluation for underlying causes'.) Prevention and management of medical complications Patients with acute or chronic SDH are at risk for medical complications due to immobility or direct effects of the SDH. These complications can be associated with worse outcomes based on data from patients with intracerebral hemorrhage [45]. Seizure prophylaxis and management Patients with SDH are at risk for seizure or status epilepticus [46]. We do not routinely start antiseizure medicine prophylaxis for patients who have not had a seizure. In systematic reviews and observational studies, the seizure rate appears similar whether or not patients with SDH receive antiseizure medication prophylaxis [46-49]. https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 13/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate For patients with impairment of consciousness not attributed to mass effect from the SDH, we evaluate for other causes of symptoms. This includes electroencephalography to assess for nonconvulsive seizures or status epilepticus. (See 'Evaluation for underlying causes' above.) Antiseizure medications are typically reserved for patients with SDH who have clinical or electrographic seizures. The choice of initial antiseizure medication is guided by medical comorbidities, drug interactions, side effect drug profile, and contraindications ( table 6). (See "Evaluation and management of the first seizure in adults".) Prevention of venous thromboembolism Patients hospitalized with an acute illness and those with a neurologic condition that impairs mobility are at risk for venous thromboembolism. Intermittent pneumatic compression should be started on the first day of hospital admission for patients with SDH and impaired mobility. We add chemical prophylaxis for most patients one to four days after SDH stability is documented. An exception would be some patients being evaluated for urgent surgery for whom chemical prophylaxis may be temporarily withheld. (See "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".) Therapies not recommended or of uncertain benefit Statin medications Limited data suggest that low-dose statin medications may reduce hematoma size for patients with chronic SDH. In a systematic review that identified 156 patients with chronic SDH from three observational studies, atorvastatin 20 mg daily for one to six months was associated with reduced hematoma volume and low rates of recurrence [50]. In a trial of 196 patients with chronic SDH from China, those assigned atorvastatin 20 mg daily had better outcomes at eight weeks than those assigned to placebo, including greater reduction in SDH volumes (29 versus 17 mL) and lower rates of surgery for hematoma enlargement or deterioration (11 versus 24 percent; hazard ratio 0.47, 95% CI 0.24-0.92) [51]. Additional studies are needed to better identify the role of statin medications in the nonoperative management of patients with chronic SDH. Tranexamic acid The role of tranexamic acid (TXA) in the nonoperative management of patients with SDH is uncertain. TXA is an antifibrinolytic agent used in some patients with chronic SDH to reduce the rate of rebleeding after surgery or to promote resorption [52]. In a systematic review of 105 patients from four studies, only low-quality evidence was identified showing that tranexamic acid was associated with reduction in hematoma volume [53]. Data were limited by small numbers and variability in patient characteristics. In addition, TXA was used as an adjunctive therapy to surgical evacuation in most cases. In https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 14/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate an observational study of 27 patients with chronic SDH managed nonoperatively including TXA for a mean of 65 days, resolution occurred in all patients and no complications were reported [54]. Additional trial data are needed to clarify the role of TXA for patients with chronic SDH. Glucocorticoids We avoid glucocorticoid therapy for patients with SDH. In a trial of 748 patients with symptomatic chronic SDH, those assigned to a two-week course of dexamethasone were less likely to achieve a good functional outcome at six months than those assigned to placebo (84 versus 90 percent) [55]. Glucocorticoid therapy has also been associated with increased acute mortality following head injury. This issue is discussed separately. (See "Management of acute moderate and severe traumatic brain injury", section on 'Glucocorticoids'.) PROGNOSIS AND LONG-TERM MANAGEMENT The prognosis of SDH depends on severity of SDH and associated medical comorbidities. In a study that included 746 procedures of patients with SDH who underwent surgery between 2005 and 2012, the 30-day mortality rate was 17 percent [56]. In another study assessing outcome of patients undergoing surgery for acute SDH that included 462 patients (median age 49 years old), mortality at six months was 31 percent [8]. The estimated mortality rate for patients with more severe injuries who require surgery for SDH is as high as 60 percent in some small studies [1,3,9,29,33,40]. For patients who presented with coma prior to surgical evacuation, mortality rates were 57 to 68 percent [1,34,57]. Risk factors for poor outcome Age greater than 60 years and severe neurologic impairment are important prognostic indicators in patients with acute SDH [9,34]. Clinical features associated with poor outcome after SDH include the following: Older age [34,56] Lower Glasgow Coma Scale score [9,39] Coma at presentation [56,57] Coagulopathy [1,56,58] In addition, several studies have identified head computed tomography (CT) findings that correlate with poor outcome after acute SDH, including the following: Hematoma thickness [3,35] Hematoma volume [36] Presence and/or degree of midline brain shift [3,34-36] https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 15/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Reduced patency of the basal cisterns [35] Coexisting intraparenchymal injury [33,58] Arterial source to SDH [59,60] However, some studies have not confirmed these relationships [61]. Risk of recurrence Recurrence of an acute SDH after initial resolution is uncommon and usually associated with an underlying fixed bleeding source such as a dural arteriovenous malformation, metastases, liver failure, hematological malignancies, or intracranial hypotension [62-65]. The risk of recurrence may be higher in patients with spontaneous SDH than those with a clear precipitant such as trauma. Recurrence of chronic SDH has been described in 5 up to 30 percent of patients [66-68]. Older age, thicker hematoma width, and bilateral presentation have been linked to higher rates of recurrence [68-73]. Ongoing antiplatelet and anticoagulant therapy may also increase the risk of recurrent SDH, although this has not been consistently found [72,74,75]. The use of postoperative drainage is associated with a lower risk of secondary recurrence. Resumption of antithrombotic medications The decision to resume anticoagulant or antiplatelet medications that were discontinued during initial SDH management should be individualized balancing the strength of the specific indication for therapy with the risk of SDH recurrence. We suggest resuming antiplatelet therapy after SDH resolution for most patients with a specific indication for such therapy. In one study of 2939 patients with SDH, the risk of subsequent arterial ischemic events was elevated in the first four weeks after SDH (hazard ratio 3.6, 95% CI 1.9-5.5), driven largely by patients with strong indications for antithrombotic therapy [76]. Accordingly, the risk-benefit analysis might favor resumption of antiplatelet therapy in a patient with active coronary or vascular disease, particularly after a SDH related to a traumatic injury that was not likely to recur. Many patients will benefit from resuming anticoagulation when the thromboembolic risk is higher than the risk of recurrent SDH. The specific risks and benefits should be weighed for individual patients. As examples: Anticoagulation may be resumed for selected patients with a traumatic SDH and atrial fibrillation with an elevated risk of thromboembolism after follow-up head CT shows resolution of the hematoma. (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".) https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 16/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Anticoagulation may be resumed for selected patients with a spontaneous SDH and a history of deep venous thrombosis and a high recurrence risk after follow-up head CT shows resolution of the hematoma. (See "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation", section on 'High recurrence risk'.) Anticoagulation may be withheld for selected patients with SDH and a high risk of recurrence, such as those with SDH due to a secondary source such as an unsecured arteriovenous malformation that has bled or cerebral amyloid angiopathy. (See "Brain arteriovenous malformations", section on 'Ruptured AVMs' and "Cerebral amyloid angiopathy", section on 'Managing anticoagulant and antiplatelet medications'.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topic (see "Patient education: Subdural hematoma (The Basics)") SUMMARY AND RECOMMENDATIONS Initial management Subdural hematoma (SDH) can be a neurologic emergency that may cause irreversible brain injury and death caused by hematoma expansion, elevated https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 17/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate intracranial pressure (ICP), and brain herniation. Patients with SDH require urgent assessment of clinical status, the management of any antithrombotic medications, and evaluation of the need for immediate surgery ( table 1). (See 'Initial management' above.) Surgical management Urgent surgical hematoma evacuation is required for patients with SDH and signs attributable to brain herniation or elevated ICP and for those with clinical deterioration due to hematoma expansion ( algorithm 1). (See 'Surgical indications and approaches' above.) We also suggest surgical hematoma evacuation for patients with clot thickness >10 mm or midline shift >5 mm on initial brain scan especially if there is neurologic deterioration (Grade 2C). For other patients, we monitor nonoperatively with close neurologic monitoring for clinical or radiographic deterioration. Nonoperative management for all others Nonoperative management of SDH may be appropriate for patients who are clinically stable and have small hematomas with no signs of brain herniation (ie, midline shift <5 mm) or elevated ICP. Patients with SDH managed nonoperatively are closely monitored to assess for subsequent deterioration ( algorithm 1). (See 'Nonoperative management' above.) Monitoring Neurologic examinations should be performed at baseline and every one to two hours for at least the first 24 hours. Examinations include assessments of alertness, pupillary and other bulbar functions, sensorimotor functions, and Glasgow Coma Scale scoring ( table 2). (See 'Monitoring' above.) Repeat imaging Surveillance follow-up imaging with head computed tomography (CT) should be obtained within six to eight hours of the initial scan for all patients with SDH. Urgent repeat head CT is warranted for all patients who have an acute deterioration in clinical status. (See 'Follow-up imaging' above and 'Urgent repeat imaging to assess for indication for surgery' above.) Patients who deteriorate Surgical evacuation is indicated when clinical deterioration is due to significant progression of the hematoma. Testing for other causes is warranted for patients with SDH and evidence of clinical deterioration not accounted for by findings on repeat head CT. (See 'Management of patients who deteriorate' above.) Resumption of antithrombotic medications The decision should be individualized balancing the strength of the specific indication for therapy with the risk of SDH recurrence. Many patients will benefit from resuming anticoagulation when the https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 18/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate thromboembolic risk is higher than the risk of recurrent SDH. (See 'Resumption of antithrombotic medications' above.) Prognosis The 30-day mortality rate in patients with SDH who underwent surgery is approximately 17 percent but may be higher in patients who present with clinical features such as older age, preexisting coagulopathy, severe deficits on exam, and imaging features such as larger SDH volume, brain compression, or coexisting intraparenchymal injury. (See 'Risk factors for poor outcome' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58:S16. 2. Uno M, Toi H, Hirai S. 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Anticoagulants and antiplatelet agents and the risk of development and recurrence of chronic subdural haematomas. J Clin Neurosci 2009; 16:1287. 76. Murthy SB, Wu X, Diaz I, et al. Non-Traumatic Subdural Hemorrhage and Risk of Arterial Ischemic Events. Stroke 2020; 51:1464. Topic 1110 Version 26.0 https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 24/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate GRAPHICS Subdural hematoma in adults: Rapid overview of emergency management Clinical manifestations When to suspect: Trauma Unexplained acute or subacute progressive neurologic symptoms New neurologic symptoms in an older patient (especially if taking anticoagulants) Common symptoms: New and persistent headache, focal or bilateral weakness, confusion, subacute cognitive decline, seizures Signs of elevated intracranial pressure: Dilated pupil(s) Progressive drowsiness Cushing triad (bradycardia, respiratory depression, hypertension) Evaluation Assess airway, breathing, circulation, and disability to initiate supportive care Determine GCS and neurologic deficits (eg, hemiparesis, numbness, speech or vision impairment) Identify exposure to anticoagulant medications (eg, warfarin, DOACs, heparinoids) Obtain emergency imaging (eg, head CT or fast MRI) Laboratory evaluation: Complete blood count, PT, PTT, INR, basic electrolytes, pregnancy test in female of childbearing age Initial serial monitoring: Neurologic examination (hourly) for signs of deterioration Repeat head CT 6 to 8 hours after initial study and for any clinical signs of deterioration Treatment Manage trauma patients according to principles of advanced trauma life support* Perform tracheal intubation for any patient unable to protect their airway, with rapidly deteriorating mental status, or with GCS 8 https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 25/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Obtain immediate neurosurgical consultation as indicated by clinical signs or imaging: Hemispheric SDH >10 mm thickness or midline shift >5 mm SDH causing brainstem compression or pupillary abnormalities SDH causing progressive neurologic deterioration (eg, GCS drop 2 points) Reverse anticoagulation (agent specific): Warfarin Reverse with 4-factor PCC and IV vitamin K Dabigatran Reverse with idarucizumab Factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) Reverse with 4-factor PCC or andexanet alfa Heparin (unfractionated) Reverse with protamine sulfate Low molecular weight heparin Reverse with andexanet alfa; protamine sulfate is an alternative Medical management of intracranial pressure: Blood pressure control: Prevent HYPOtension to maintain SBP >100 mmHg: fluid resuscitation with isotonic IV fluids; phenylephrine for refractory symptoms Initial dose 0.5 to 2 mcg/kg per minute IV; maintenance dose 0.25 to 5 mcg/kg per minute Treat HYPERtension: Initial treatment to rapidly reduce SBP to <220 mmHg: nicardipine 5 mg/hour IV, titrate by 2.5 mg/hour every 5 to 15 minutes (maximum dose: 15 mg/hour); alternate: labetalol 20 mg IV bolus, may repeat every 10 minutes Subsequent treatment to reduce SBP to <160 mmHg while monitoring for stability of neurologic status Elevate head of bed >30 degrees Give antipyretics for temperature >38 degrees Celsius (eg, acetaminophen [paracetamol] 325 to 650 mg orally or PR every 4 to 6 hours or 650 mg IV every 4 hours) Repeat imaging (eg, head CT) for signs of new or progressive elevated intracranial pressure: Obtain immediate neurosurgical consultation for surgical indications (refer to above) Osmotic therapy (mannitol or hypertonic saline) or hyperventilation as temporary treatment measures https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 26/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate GCS: Glasgow coma scale; DOAC: direct oral anticoagulant; CT: computed tomography; MRI: magnetic resonance imaging; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; SDH: subdural hematoma; PCC: prothrombin complex concentrate; IV: intravenous; SBP: systolic blood pressure; PR: per rectum. Refer to the UpToDate topics on trauma management in adults. Refer to the UpToDate topics on management of elevated intracranial pressure in adults. Graphic 132691 Version 5.0 https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 27/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Management of acute and symptomatic chronic subdural hematoma SDH: subdural hematoma; CT: computed tomography; EEG: electroencephalogram; MRI: magnetic resonance imaging. For patients with trauma, follow principles of advanced trauma life support. https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 28/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Refer to the UpToDate on reversal of anticoagulation in intracranial hemorrhage for additional details. Glasgow Coma Scale drop 2+ points; worsening of neurologic exam including pupillary abnormalities, cranial nerve palsies, and limb weakness. Includes patients with nontraumatic SDH without cerebral atrophy, coagulopathy, or other risk factors to explain SDH. Refer to the UpToDate topic on the etiology, clinical features, and diagnosis of subdural hematoma in adults for additional details. Graphic 134178 Version 1.0 https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 29/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/subdural-hematoma-in-adults-management-and-prognosis/print 30/47 7/5/23, 12:02 PM Subdural hematoma in adults: Management and prognosis - UpToDate Emergency reversal of anticoagulation from warfarin for life-threatening hemorrhage in adults: Suggested approaches based upon available resources A. If 4-factor prothrombin complex concentrate (4F PCC) is available (preferred approach): 1. Give 4F PCC* 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion of the infusion. If INR is not 1.5, give additional 4F PCC (refer to topic or drug reference for details). 2. Give vitamin K 10 mg IV over 10 to 20 minutes. B. If 3-factor prothrombin complex concentrate (3F PCC) is available but 4F PCC is not available: 1. Give 3F PCC* 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion of the infusion. If INR is not 1.5, give additional 3F PCC (refer to topic or drug reference for details). 2. Give Factor VIIa 20 mcg/kg IV OR give FFP 2 units IV by rapid infusion. Factor VIIa may be preferred if volume overload is a concern. 3. Give vitamin K 10 mg IV over 10 to 20 minutes. C. If neither 3F PCC nor 4F PCC is available: 1. Give FFP 2 units IV by rapid infusion. Check INR 15 minutes after completion of infusion. If INR 1.5, administer 2 additional units of FFP IV rapid infusion. Repeat process until INR 1.5. May wish to administer loop diuretic between FFP infusions if volume overload is a concern. 2. Give vitamin K 10 mg IV over 10 to 20 minutes. These products and doses are for use in life-threatening bleeding only. Evidence of life-threatening bleeding and over-anticoagulation with a vitamin K antagonist (eg, warfarin) are required. Anaphylaxis and transfusion reactions can occur. It may be reasonable to thaw 4 units of FFP while awaiting the PT/INR. The transfusion service may substitute other plasma products for FFP (eg, Plasma Frozen Within 24 Hours After Phlebotomy