From the Guidelines
The 76-year-old patient with bilateral hemorrhages and midline shift requires immediate neurosurgical intervention for emergency surgical evacuation of the hemorrhages, particularly the subdural hemorrhage causing compression and midline shift, as recommended by the most recent guidelines 1.
Key Considerations
- The patient should be transferred to a neurosurgical center as soon as possible for emergency surgical intervention.
- Prior to surgery, the patient needs stabilization with airway management, potentially requiring intubation and mechanical ventilation to maintain adequate oxygenation.
- Mannitol (0.5-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) should be administered to reduce intracranial pressure, as suggested by guidelines for managing severe traumatic brain injury 1.
- Seizure prophylaxis with levetiracetam (500-1000 mg IV twice daily) is recommended to prevent further complications.
- Blood pressure should be carefully controlled, maintaining systolic pressure between 100-160 mmHg to ensure adequate cerebral perfusion without exacerbating bleeding, in line with recommendations for managing severe adult traumatic brain injury patients with polytrauma 1.
- Any anticoagulant or antiplatelet medications should be reversed immediately; for warfarin, administer vitamin K (10 mg IV) and prothrombin complex concentrate; for direct oral anticoagulants, specific reversal agents like idarucizumab or andexanet alfa may be needed.
Post-Surgical Care
- Post-surgery, the patient will require ICU monitoring with frequent neurological assessments, ICP monitoring, and gradual rehabilitation.
- Maintaining a cerebral perfusion pressure (CPP) ≥ 60 mmHg when ICP monitoring becomes available is crucial, with adjustments based on neuromonitoring data and the cerebral autoregulation status of the individual patient, as recommended by the WSES consensus conference guidelines 1.
- A stepwise approach to managing elevated ICP, reserving more aggressive interventions for situations when no response is observed, is advisable 1.
From the Research
Management of Head Injury
To manage a 76-year-old patient with a history of head injury, presenting with a subdural hemorrhage of the left frontoparietal region and an extra-axial hemorrhage in the right frontoparietal region, with compression effect on the right lateral ventricle and midbrain, and a midline shift, the following steps can be considered:
- Evaluate the patient's clinical and anamnestic parameters upon arrival in the Emergency Department, as emphasized in 2
- Consider the patient's age, injury type, and presence of any comorbidities, such as coagulopathy or antithrombotic drug use
- Perform a computed tomography (CT) scan to assess the extent of the injury and identify any potential complications, as recommended in 3
Monitoring and Follow-up
- Monitor the patient's neurological status and perform serial CT scans to assess for any changes in the hematoma size or midline shift, as suggested in 4 and 5
- Consider the risk factors for delayed hematoma enlargement, including hematoma volume and degree of midline shift on the initial CT scan, as identified in 5
- Be aware that a significant proportion of patients with minimal acute subdural hematomas can progress over several weeks and require hematoma evacuation, as reported in 5
Treatment Options
- Consider the use of hyperosmolar agents, such as mannitol or hypertonic saline, to control high intracranial pressure, as discussed in 6
- Be aware that the current evidence suggests that hypertonic saline is as effective as mannitol at reducing increased intracranial pressure, but there is not enough data to recommend the optimal and safest dose concentration, as noted in 6
- Consider surgical evacuation of the hematoma if there is significant enlargement or if the patient's neurological status deteriorates, as suggested in 5