Management of Acute-on-Chronic Subdural Hemorrhage

Immediate Blood Pressure Control

The American College of Cardiology recommends immediately targeting systolic blood pressure to 140-160 mmHg within the first 6 hours using intravenous nicardipine or labetalol, while simultaneously obtaining urgent neurosurgical consultation, to prevent hematoma expansion in patients with acute-on-chronic subdural hemorrhage and hypertension 1

The American Society of Anesthesiologists recommends securing the airway if Glasgow Coma Scale ≤8, loss of protective reflexes, or inability to maintain PaO2 ≥13 kPa (approximately 98 mmHg) in patients with acute-on-chronic subdural hemorrhage 2
The European Society of Anaesthesiology recommends using high-dose fentanyl (3-5 µg/kg) or remifentanil with ketamine (1-2 mg/kg) for induction in hemodynamically unstable patients to maintain adequate mean arterial pressure 2
The American Heart Association recommends establishing invasive arterial blood pressure monitoring with transducer at the level of the tragus before or immediately after intubation in patients with acute-on-chronic subdural hemorrhage 2

The American College of Cardiology recommends targeting systolic blood pressure 140-160 mmHg within 6 hours to prevent hematoma expansion in patients with acute-on-chronic subdural hemorrhage 1
The European Society of Cardiology recommends maintaining mean arterial pressure >80 mmHg (or systolic BP >100 mmHg) to ensure adequate cerebral perfusion in patients with acute-on-chronic subdural hemorrhage 3
The American College of Cardiology recommends maintaining cerebral perfusion pressure ≥60 mmHg at all times if intracranial pressure monitoring is available in patients with acute-on-chronic subdural hemorrhage 1
The American College of Cardiology recommends avoiding excessive blood pressure reduction >70 mmHg within the first hour, particularly if presenting with systolic BP ≥220 mmHg, as this increases risk of acute kidney injury and mortality in patients with acute-on-chronic subdural hemorrhage 1

The World Federation of Neurosurgical Societies recommends performing immediate neurological assessment including pupils and Glasgow Coma Scale motor score in patients with acute-on-chronic subdural hemorrhage 3
The World Federation of Neurosurgical Societies recommends obtaining urgent non-contrast CT brain scan to determine severity of brain damage and presence of life-threatening mass effect in patients with acute-on-chronic subdural hemorrhage 3

The European Society of Cardiology recommends administering 0.3-1.0 mg/kg slow IV bolus every 10 minutes or continuous infusion 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr of labetalol in patients with acute-on-chronic subdural hemorrhage and hypertension 4, 1
The European Society of Cardiology recommends avoiding short-acting nifedipine due to unpredictable and excessive blood pressure drops in patients with acute-on-chronic subdural hemorrhage 5
The European Society of Cardiology recommends avoiding hydralazine due to unpredictable response and prolonged duration of action in patients with acute-on-chronic subdural hemorrhage 6
The European Society of Cardiology recommends avoiding nitroprusside as it can increase intracranial pressure in patients with acute-on-chronic subdural hemorrhage 4

The World Federation of Neurosurgical Societies recommends that all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation after control of any life-threatening hemorrhage in patients with acute-on-chronic subdural hemorrhage 3
The World Federation of Neurosurgical Societies recommends that surgery should not be delayed if there is significant mass effect or neurological deterioration, even while optimizing blood pressure in patients with acute-on-chronic subdural hemorrhage 3

The American Society of Anesthesiologists recommends obtaining full blood count and coagulation screen immediately in patients with acute-on-chronic subdural hemorrhage 2
The European Heart Journal recommends reversing any anticoagulation or antiplatelet therapy as clinically indicated in patients with acute-on-chronic subdural hemorrhage 4
The American College of Cardiology recommends monitoring blood pressure every 15 minutes until stabilized, then every 30-60 minutes for first 24-48 hours in patients with acute-on-chronic subdural hemorrhage 1
The American College of Cardiology recommends performing hourly neurological assessments using validated scales for first 24 hours in patients with acute-on-chronic subdural hemorrhage 1
The World Federation of Neurosurgical Societies recommends transfusing red blood cells if hemoglobin <7 g/dL during interventions in patients with acute-on-chronic subdural hemorrhage 3
The American Thoracic Society recommends maintaining PaO2 between 60-100 mmHg (peripheral oxygen saturation ≥95%) in patients with acute-on-chronic subdural hemorrhage 2, 3