What are the conservative treatments for subdural hematoma?

In addition to surgical treatment, subdural hematoma can also be treated with non-surgical methods based on the patient's actual condition. However, non-surgical conservative treatment is mainly suitable for patients with clear consciousness, stable condition, and basically normal vital signs.

1. Non-surgical treatment: Acute and subacute subdural hematoma must be treated with timely and reasonable non-surgical treatment regardless of whether surgery is performed or not, especially after surgery for acute hematoma. Although some acute subdural hematomas can dissipate spontaneously, they are very rare and one should not take chances. In fact, only a small number of patients with subacute subdural hematoma can receive non-surgical treatment if the primary brain injury is relatively mild and the disease progresses slowly. Indications are: clear consciousness, stable condition, basically normal vital signs, and gradually alleviated symptoms; localized brain compression causing neurological impairment; CT scan shows no significant compression of the ventricles and cisterns, hematoma less than 40ml, and midline shift no more than 10mm; intracranial pressure monitoring pressure is below 3.33~4.0kPa (25~30mmHg).

2. Drilling and irrigation drainage: Drilling and drainage are performed according to the location of the hematoma shown on CT. If it is an emergency drilling exploration that is too late to locate the site before the operation, the site should be located according to the injury mechanism and focus point combined with the patient's clinical manifestations, and then the holes should be drilled in sequence. If it is a contralateral injury, the hole should be drilled in the frontal temporal area first, followed by the forehead and then the top of the head; if it is a direct impact injury, the hole should be drilled first at the impact site and then at the contralateral site. When a hematoma is discovered, the drill hole should be slightly enlarged to facilitate flushing and removal of the hematoma. If it is a liquid hematoma and there is no active bleeding, 1 to 2 more holes can be drilled in the thicker part of the hematoma, and then most of the hematoma can be discharged by flushing through catheters inserted between the holes. At this point, if the intracranial hypertension is relieved and the brain pulsation is good, the operation can be terminated. A drainage tube is left in a low position for continuous drainage for 24 to 48 hours, and the scalp is sutured in layers. In children with acute subdural hematoma and patent fontanelles, repeated aspiration can be performed through puncture at the lateral angle of the anterior fontanelle to gradually drain the hematoma. If the hematoma is solid, drilling and drainage or craniotomy are required to remove the hematoma.

3. Treatment of postoperative hematoma recurrence: Whether it is drilling irrigation drainage or craniotomy resection, there is a problem of hematoma recurrence. Common causes of recurrence include: brain atrophy in elderly patients, difficulty in brain swelling after surgery; thick hematoma capsule, inability to close the subdural space; blood clots in the hematoma cavity that have not been completely removed; fresh bleeding leading to hematoma recurrence. Therefore, precautions must be taken. After the operation, the patient should keep the head low and lie on the affected side, drink plenty of water, do not use strong dehydrating agents, and supplement with hypotonic fluids appropriately when necessary. For those with thick capsule or calcification, craniotomy should be performed to remove it. When there is solid blood clot in the hematoma cavity, or when there is fresh bleeding, a bone flap or window craniotomy should be used to completely remove it. After the operation, the drainage tube is used to vent air at a high position and drain fluid at a low position. Both are connected to an external closed drainage bottle (bag). At the same time, normal saline is injected through lumbar puncture or cerebral ventricle. It takes 10 to 20 days for the absorption of residual fluid and gas accumulation and the swelling of brain tissue after surgery. Therefore, dynamic CT observation should be performed. If the clinical symptoms have improved significantly, there is no need to rush for another surgery even if there is still fluid accumulation under the dura mater.