This is the current release of the guideline.

Acute subdural hematoma (SDH)

Management
Treatment

Emergency Medicine
Neurological Surgery
Neurology

Physicians

To define the subset of patients who would benefit from surgical evacuation of an acute subdural hematoma

Patients with an acute subdural hematoma

1. Surgical evacuation (craniotomy with or without bone flap removal and duraplasty in a comatose patient (GCS <9)
2. Computed tomography (CT) scan
3. Glasgow Coma Scale score
4. Intracranial pressure monitoring
5. Timing of surgery
6. Pupillary exam
7. Neurological monitoring
8. Nonoperative treatment

• Mortality rate
• Level of disability/functional recovery
• Efficacy of surgical technique

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

A MEDLINE computer search using the following keywords for the years 1975 to 2001 was performed: "traumatic brain injury" or "head injury" and "subdural" or "intradural" and "hematoma" or "hemorrhage." The search was narrowed by including the keywords "surgical treatment" or "surgery" or "operation" or "craniotomy" or "craniectomy" or "craniostomy" or "burr holes" and excluding "chronic" and "spinal." Case reports, publications in books, and publications regarding penetrating brain injuries, or spinal or chronic subdural hematoma (SDH) were not included. Chronic SDH was defined as an SDH occurring or diagnosed more than 14 days after trauma. Articles were excluded if the diagnosis of SDH was not based on computed tomographic (CT) scanning, or if subgroups of patients who did not undergo CT scanning were not clearly identified. Publications with fewer than 10 patients or publications that did not include information on outcome were excluded.

These searches combined yielded 161 articles. The reference lists of these publications were reviewed and an additional 18 articles were selected for analysis. Of these 179 articles, 21 were selected for analysis.

Weighting According to a Rating Scheme (Scheme Given)

Classification of Evidence

When assessing the value of therapies or interventions, the available data was classified into one of the following three categories according to the following criteria:

Class I: Evidence from one or more well-designed, randomized, controlled clinical trials, including overviews of such trials

Class II: Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies

Class III: Evidence from case series, comparative studies with historical controls, case reports, and expert opinion

Systematic Review with Evidence Tables

Evaluation and Weighting of the Evidence

The journal articles found have been carefully read and evaluated, including an assessment of the methodology used in the studies. This not only includes the establishment of the clinical question addressed (e.g., therapeutic effectiveness, diagnostic tests, prognostic studies, etc.) and type of study (randomized controlled trial, case-control study, case series, etc.), but also the quality of the study with respect to potential errors in design, execution, or conclusions reached. Therefore, studies that might, on the surface, represent evidence supporting one level of recommendation, may instead be flawed enough to be devalued to support a recommendation of lesser strength. The quality of the literature was evaluated in this way according to well-established criteria. All articles were cross-reviewed and disagreements were resolved by consensus.

Expert Consensus

Link Between Evidence and Guidelines

The general concept of relating strength of recommendations to strength of evidence reflecting varying degrees of clinical certainty was formalized into a scheme that has been followed by medical societies, including organized neurosurgery, from the inception of the Guideline development process. Despite problems with the strict application of this paradigm (some of which are displayed and discussed in this supplement), the scheme has the benefit of using scientific evidence rather than expert opinion for the substrate of the recommendations, although expert opinion is used to formulate the recommendations themselves, as well as to make judgments regarding the quality of the evidence. The evidence-based scheme used in these and all Guidelines regarding therapeutic effectiveness endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons begins with classification of the literature into three categories of evidence (see "Rating Scheme for the Strength of the Evidence" above).

The classification of evidence into these three categories leads to the formulation of recommendations called Standards, Guidelines, and Options. Class I evidence is used to support treatment recommendations of the strongest type, practice Standards, reflecting a high degree of clinical certainty. Class II evidence is used to support Guidelines, reflecting a moderate degree of clinical certainty. Class III evidence supports practice Options reflecting unclear clinical certainty. This terminology was developed to indicate, in normal vocabulary, the strength of the recommendations on the basis of strong to weak medical evidence. In neurosurgery, this scheme has been used to formulate Guidelines, rather than a scheme that uses letters or numbers that have no grounding in language and are, therefore, more easily misinterpreted. The link between scientific evidence and recommendations has been highlighted in these Guidelines by presenting those studies in the scientific foundation that support the stated recommendation in boldface type.

Expert Judgment and Empirical Evidence

There are two ways in which expert judgment comes into Guideline development. The most common use of expert opinion is in developing recommendations for practice. This has been a usual method in the past (as well as the present, in the form of textbook chapters), but has more recently given way to more formalized approaches embraced by evidence-based medicine methodology, such as that used in this supplement. However, even in evidence-based methodology, expert opinion is used to evaluate the literature as well as to frame the concepts and wording of the recommendations. In addition, if the evidence is weak and conflicting, expert opinion is used to derive recommendations. This use is unavoidable, but the expert opinion is guided by the evidence published in the literature, rather than from personal experience alone.

Levels of Recommendations

Standards: Represent accepted principles of patient management that reflect a high degree of clinical certainty.

Guidelines: Represent a particular strategy or range of management strategies that reflect a moderate degree of clinical certainty.

Options: Are the remaining strategies for patient management for which there is unclear clinical certainty.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

In all Guidelines published under the auspices of the Brain Trauma Foundation and the American Association of Neurological Surgeons, other professional organizations were involved in either developing the Guidelines or reviewed and approved them. In these Surgical Management of Traumatic Brain Injury Guidelines, however, only neurosurgeons were involved. These neurosurgeons represent a wide range of organizations. There were representatives from the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the European Brain Injury Consortium, the American College of Surgeons (Committee of Trauma) and the World Federation of Neurological Surgeons (Neurotrauma section) involved in the development of these Surgical Management of Traumatic Brain Injury Guidelines.

"Degrees of Certainty" [Standards, Guidelines, Options] and "Classification of Evidence" [Class I to III] are defined at the end of the "Major Recommendations" field.

Note: All of the following recommendations are at the Option level supported only by Class III scientific evidence.

Recommendations

Indications for Surgery

• An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift (MLS) greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score.
• All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.
• A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.

Timing

• In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.

Methods

• If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

Summary

In patients with an acute SDH, clot thickness or volume and the MLS on the preoperative CT correlate with outcome. In studies analyzing CT parameters that may be predictive for delayed surgery in patients undergoing initial nonoperative management, an MLS greater than 5 mm or a clot thickness greater than 10 mm on the initial CT scan emerged as significant prognostic factors (see Appendices in the original guideline document for measurement techniques). Therefore, patients with SDH presenting with a clot thickness greater than 10 mm or an MLS greater than 5 mm should undergo surgical evacuation, regardless of their GCS. Patients who present in a coma (GCS < 9) but with an SDH with a thickness less than 10 mm and an MLS less than 5 mm can be treated nonoperatively, providing that they undergo ICP monitoring, they are neurologically stable since the injury, they have no pupillary abnormalities, and they have no intracranial hypertension (ICP >20 mm Hg). Because of the frequent association of SDH with parenchymal injury, surgical management decisions should take into consideration the recommendations for both lesion types.

Definitions:

Degrees of Certainty

Standards: Represent accepted principles of patient management that reflect a high degree of clinical certainty.

Guidelines: Represent a particular strategy or range of management strategies that reflect a moderate degree of clinical certainty.

Options: Are the remaining strategies for patient management for which there is unclear clinical certainty.

Classification of Evidence on Therapeutic Effectiveness

Class I: Evidence from one or more well-designed, randomized, controlled clinical trials, including overviews of such trials

Class II: Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies

Class III: Evidence from case series, comparative studies  with historical controls, case reports, and expert opinion

None provided

The recommendations are all at the Option level, supported only by Class III scientific evidence (e.g., evidence from case series, comparative studies with historical controls, case reports, and expert opinion)

Appropriate surgical management of subdural hematoma (SDH) to improve clinical outcomes and reduce morbidity and mortality

Not stated

As in all other areas of evidence-based medicine,  these Guidelines have been formulated strictly in accordance with externally imposed constraints. Only clinical human-based literature has been reviewed. Only literature from 1975 through 2001 has been reviewed. Mainly literature in English, with far fewer articles in other languages, was reviewed. For these reasons, the reader must clearly understand that the scope and level of magnitude of the recommendations made here are distilled from the available literature and interpreted according to the rules of evidence-based medicine.

An implementation strategy was not provided.

Getting Better

Effectiveness
Timeliness

Not applicable: The guideline was not adapted from another source.

2006 Mar

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation
Integra NeuroSciences

Not stated

Authors: M. Ross Bullock, MD, PhD, Department of Neurological Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia; Randall Chesnut, MD, Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington; Jamshid Ghajar, MD, PhD,  Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York; David Gordon, MD, Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York; Roger Hartl, MD, Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York; David W. Newell, MD,  Department of Neurological Surgery, Swedish Medical Center, Seattle, Washington; Franco Servadei, MD, Department of Neurological Surgery, M. Bufalini Hospital, Cesena, Italy; Beverly C. Walters, MD, MSc, Department of Neurological Surgery, New York University School of Medicine, New York, New York; Jack E. Wilberger, MD, Department of Neurological Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

Not stated

Congress of Neurological Surgeons - Professional Association

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on August 15, 2006. The information was verified by the guideline developer on August 18, 2006.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.