This is the current release of the guideline.

"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)

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.