A Prospective Study on Acute Subdural Hematoma in Mild Head Injury Patients: Outcome with Initial Nonoperative Management

Abstract

Introduction Incidence of acute subdural hematoma (SDH) is 21% in head injury patients. Decompressive craniectomy done for acute SDH itself carries a very high morbidity and mortality. The skull bone defect, prolonged hospital stay, the need of a second surgery (cranioplasty), and bone flap infection are other problems associated with decompressive craniectomy. Hence, this study looks into the outcome of conservative management in acute SDH in patients with mild head injury.

Aims and Objectives The main objective of this article is to study the patients included in the study with regard to outcome, morbidity, duration of hospital stay, and hospital cost. This article also studies the efficacy and outcome of lesser aggressive management (burr-hole evacuation) after initial nonoperative management of the patients included in the study.

Materials and Methods This is a prospective study performed in the Department of Neurosurgery, Gauhati Medical College and Hospital. A total of 30 patients arriving in the emergency department during a 6-month period from December 1, 2017 to May 31, 2018 with a diagnosis of acute SDH and with Glasgow coma scale (GCS) 13 to 15 were evaluated. Evaluation was done by history, clinical examination, GCS, computed tomography (CT) (plain) scan brain, and Glasgow outcome score at 6 months follow-up.

Results and Observations Twenty patients showed complete resolution of the clot, and eight patients had liquefaction of clot which was evacuated by burr-hole. One mortality was recorded and one had to undergo decompressive craniectomy. About 93.33% of patients managed by initial nonoperative management showed functionally independent outcome at 6 months follow-up.

Conclusion Conservative management in patients with acute SDH can be a viable alternative in certain cases. Those patients with GCS of 13 and above with CT scan showing midline shift of even ≥5 mm or thickness of 10 mm and more can also be managed conservatively by close monitoring.

Keywords

acute subdural hematoma - conservative treatment - traumatic brain injury

• References

• 1 Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med 1981; 304 (25) 1511-1518
• 2 Wilberger Jr JE, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 1991; 74 (02) 212-218
• 3 Fell DA, Fitzgerald S, Moiel RH, Caram P. Acute subdural hematomas. Review of 144 cases. J Neurosurg 1975; 42 (01) 37-42
• 4 Hatashita S, Koga N, Hosaka Y, Takagi S. Acute subdural hematoma: severity of injury, surgical intervention, and mortality. Neurol Med Chir (Tokyo) 1993; 33 (01) 13-18
• 5 Wong CW. Criteria for conservative treatment of supratentorial acute subdural haematomas. Acta Neurochir (Wien) 1995; 135 (01) (02) 38-43
• 6 Mathew P, Oluoch-Olunya DL, Condon BR, Bullock R. Acute subdural haematoma in the conscious patient: outcome with initial non-operative management. Acta Neurochir (Wien) 1993; 121 (03) [phone]
• 7 Bullock MR, Chesnut R, Ghajar J. et al. Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58 (03) Suppl S16-S24 , discussion Si-iv
• 8 Croce MA, Dent DL, Menke PG. et al. Acute subdural hematoma: nonsurgical management of selected patients. J Trauma 1994; 36 (06) 820-826 , discussion 826–827
• 9 Zumkeller M, Behrmann R, Heissler HE, Dietz H. Computed tomographic criteria and survival rate for patients with acute subdural hematoma. Neurosurgery 1996; 39 (04) 708-712 , discussion 712–713
• 10 Feliciano CE, De Jesús O. Conservative management outcomes of traumatic acute subdural hematomas. P R Health Sci J 2008; 27 (03) 220-223