How to manage a 48-year-old male with an acute 7mm left frontoparietal subdural hematoma (SDH), sulcal subarachnoid hemorrhage (SAH), minimal intracerebral hemorrhage (ICH), and bilateral parietal bone fracture?

From the Guidelines

Management of this 48-year-old male with acute subdural hematoma (SDH) requires immediate neurosurgical consultation for possible surgical intervention, as the 7mm thickness of the left frontoparietal SDH likely necessitates surgical evacuation, given that hematomas >5mm typically warrant surgery 1. The patient should be admitted to the ICU for close neurological monitoring with hourly Glasgow Coma Scale assessments, pupillary checks, and vital sign monitoring. Initial management includes:

• Head elevation to 30 degrees
• Maintaining systolic blood pressure between 100-160 mmHg
• Ensuring adequate oxygenation (O2 saturation >95%) Seizure prophylaxis with levetiracetam 500mg IV twice daily should be initiated, as seizures are a common complication of traumatic brain injuries 1. Osmotic therapy with mannitol 0.25-1g/kg IV or hypertonic saline 3% at 30ml/hour may be needed to control intracranial pressure if signs of increased pressure develop. Pain management with acetaminophen 1g every 6 hours is appropriate, avoiding NSAIDs due to bleeding risk. The bilateral parietal bone fractures extending to the temporal bone require CT angiography to rule out vascular injury, as recommended by the American Heart Association/American Stroke Association guidelines for the management of aneurysmal subarachnoid hemorrhage 1. The small intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) should be monitored for expansion, with repeat head CT recommended within 6-24 hours depending on neurological status, to promptly identify any potential complications, such as hematoma expansion or cerebral vasospasm 1. This comprehensive approach addresses the multiple traumatic brain injuries while preventing secondary brain injury through careful monitoring and management of physiological parameters.

From the Research

Patient Assessment

To deal and manage a 48-year-old male with a history of head injury, it is essential to assess his condition using established scoring systems. The patient has an acute subdural hematoma (SDH) of thickness 7mm from the left frontoparietal region, sulcal subarachnoid hemorrhage (SAH) noted in the left temporal lobe, no significant midline shift, minimal intracerebral hemorrhage (ICH) of 1x1 cm with perilesional edema, and a fracture of the bilateral parietal bone extending to the squamous part of the temporal bone.

Scoring Systems

The Glasgow Coma Scale (GCS) is a widely used method to describe a patient's level of consciousness 2. The GCS score can be used in combination with other factors such as age and systolic blood pressure to predict mortality in trauma patients 3, 4, 5, 6. The Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) score and the Glasgow Coma Scale, Age, and Arterial Pressure (GAP) score are examples of such scoring systems.

Management

• Assess the patient's GCS score to determine his level of consciousness
• Calculate the MGAP or GAP score to predict mortality and guide management decisions
• Consider the patient's age, systolic blood pressure, and mechanism of injury when calculating the score
• Use the score to categorize the patient into a low, intermediate, or high-risk group for mortality
• Develop a management plan based on the patient's risk group and clinical condition, including monitoring, imaging, and potential surgical intervention

Key Considerations

• The patient's GCS score and MGAP or GAP score should be regularly reassessed to monitor his condition and adjust the management plan as needed
• The patient's age and comorbidities should be taken into account when developing the management plan
• The patient's mechanism of injury and the presence of other injuries should be considered when assessing his overall condition and developing the management plan