Management of Small Non-Active Bleeding Subdural Hematoma After a Fall

Initial Assessment and Imaging

The American College of Radiology recommends using CT scan as the primary diagnostic tool to confirm subdural hematoma, assess its size, location, and mass effect 1, 2
MRI with contrast may be considered if spontaneous intracranial hypotension is suspected as an underlying cause 3
Evaluate for signs of increased intracranial pressure including compression of cisternas basales, ventricular effacement, or midline shift >5mm 4

The American College of Radiology recommends conservative management with close neurological monitoring for small, asymptomatic subdural hematomas 3, 2
Maintain euvolemia to optimize cerebral perfusion 2
Bed rest may be advised, particularly if there is suspicion of underlying CSF leak 3

Development of altered consciousness is an indication for surgical intervention 2
New or worsening focal neurological deficits are indications for surgical intervention 2

Patients on anticoagulants or antiplatelet therapy require special consideration regarding medication management 2

Close outpatient follow-up is recommended for patients discharged with conservative management 2
Patient education regarding warning signs requiring immediate medical attention is crucial 2
Consider repeat imaging at 4-6 weeks to ensure resolution or stability of the hematoma 3

The American Society of Anesthesiologists recommends ensuring cerebral perfusion pressure 60-70 mmHg if ICP monitoring is in place, and maintaining systolic blood pressure >100 mmHg or mean arterial pressure 80-110 mmHg 5, 6
ICP monitoring is NOT routinely indicated for a small subdural hematoma with normal neurological exam and no mass effect, but consider ICP monitoring if neurological surveillance is not feasible, hemodynamic instability is present, or compressed basal cisterns or other severity signs exist on imaging 5, 6

The Anaesthesia society suggests that maintaining close neurological monitoring with serial examinations at least every 4 hours initially is the cornerstone of management for small, asymptomatic subdural hematomas, and optimizing cerebral perfusion by ensuring cerebral perfusion pressure 60-70 mmHg if ICP monitoring is in place 5, 6

The BEST-TRIP trial showed no difference in neurological outcome between ICP monitoring and clinical surveillance with repeated CT scans, supporting conservative monitoring in appropriate cases 5, 6