From the Research
The recommended treatment for a patient with a two-month history of head trauma presenting with vomiting, tiredness, and altered consciousness who has a subdural hematoma on CT is option B: Burr hole drainage. This surgical procedure is the standard treatment for chronic subdural hematomas, which typically develop over weeks to months following trauma. Burr holes involve creating small openings in the skull to evacuate the accumulated blood and reduce pressure on the brain. The procedure is less invasive than a craniotomy while effectively addressing the hematoma. The patient's symptoms (vomiting, tiredness, decreased consciousness) indicate significant mass effect from the hematoma requiring immediate intervention. Serial CT monitoring (option A) would be insufficient given the patient's neurological deterioration, while a craniotomy (option C) would be unnecessarily invasive for a chronic subdural hematoma unless the blood is significantly organized or there are multiple loculations. Some key points to consider in the management of subdural hematomas include:
- Maintaining intracranial pressure (ICP) below 22 mmHg, cerebral perfusion pressure (CPP) above 60 mmHg, mean arterial pressure (MAP) between 80-110 mmHg, and PaO2 above 60 mmHg, as outlined in the Emergency Neurological Life Support (ENLS) guidelines 1.
- The use of anti-seizure medications and potential reversal of antiplatelet or anticoagulant medications if neurosurgical intervention is anticipated 1.
- Post-operative care requiring ICU level monitoring and co-management by neurointensivists for optimal outcomes 1.
- Recent studies, such as the one published in 2024, suggest that delayed burr hole evacuation may be beneficial in stable patients over 55 years old with low-energy trauma and subdural hematoma, showing a decreased risk of major and minor complications compared to immediate craniotomy 2.
- Another study from 2019 compared burr hole drainage and small craniotomy for chronic subdural hematomas, finding that burr hole drainage had a lower recurrence rate, although small craniotomy was sometimes necessary for cases with solid portions or multiple septa in the hematoma 3. Given the most recent and highest quality evidence, burr hole drainage is the preferred treatment option for this patient, considering the balance between effectiveness and invasiveness, and the potential for good outcomes with rapid symptom improvement, as supported by the study from 2024 2.