What is the management of acute subdural hematoma in an elderly patient with potential complications such as hypotension, tachycardia, and impaired renal function?

From the Guidelines

Management of acute subdural hematoma in elderly patients with potential complications such as hypotension, tachycardia, and impaired renal function requires prompt neurosurgical evaluation and often surgical intervention, with a focus on reversing anticoagulation using four-factor prothrombin complex concentrates (4F-PCCs) and vitamin K, as recommended by the 2023 WSES guidelines 1.

The initial management of these patients includes:

• Airway protection, often requiring intubation with target PaCO2 of 35-40 mmHg
• Blood pressure control, maintaining systolic BP between 120-160 mmHg, as suggested by the study on blood pressure management after intracerebral and subarachnoid hemorrhage 1
• Reversal of anticoagulation, if present, using 4F-PCCs and vitamin K, as recommended by the 2023 WSES guidelines 1
• Osmotic therapy with mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) for increased intracranial pressure
• Seizure prophylaxis with levetiracetam 500-1000 mg twice daily for 7 days

Elderly patients have worse outcomes due to brain atrophy, increased vessel fragility, and higher prevalence of anticoagulant use, requiring more aggressive management of comorbidities and careful consideration of surgical risks. Post-operative care includes continued neurological monitoring, gradual mobilization, prevention of complications like pneumonia and DVT, and comprehensive rehabilitation planning.

The use of 4F-PCCs is preferred over fresh frozen plasma (FFP) for warfarin reversal due to its faster onset of action, lower risk of adverse reactions, and reduced need for blood type compatibility testing, as demonstrated by several studies 1. The recommended dose of 4F-PCCs is 25-50 U/kg, with a stepwise dosage protocol based on patient weight and presenting INR, as suggested by the FDA-approved protocol 1. Vitamin K is also recommended as an adjunct treatment to help replete stores of clotting factors and reduce the INR, with a dosage of 5-10 mg administered intravenously 1.

From the Research

Management of Acute Subdural Hematoma in Elderly Patients

The management of acute subdural hematoma in elderly patients with potential complications such as hypotension, tachycardia, and impaired renal function is a complex issue. Several studies have investigated the optimal treatment approach for this patient population.

Surgical Intervention

• A study published in 2024 2 compared delayed burr hole evacuation with acute craniotomy for acute subdural hematoma in older patients with low-energy trauma. The results showed a statistically significant increase in the incidence of any complication, major complications, and minor complications in the immediate craniotomy group compared to the delayed burr hole group.
• Another study published in 2022 3 reported a case of a 58-year-old patient who underwent emergency bedside burr hole evacuation for a large mixed subdural hematoma. The patient received recombinant tissue-type plasminogen activator (r-tPA) solution through an "anti-thrombotic catheter" left in the subdural space, resulting in clinical and radiological improvement.
• A study published in 2004 4 reported three cases of acute spontaneous subdural hematoma in aged patients treated with single burr hole drainage without irrigation. The results showed that single burr hole drainage is a less invasive method that may be beneficial for aged patients with acute spontaneous subdural hematoma.

Predictors of Outcome

• A study published in 2017 5 evaluated the incidence of acute subdural hematoma in patients 80 years or older and identified predictors of unfavorable or favorable outcome. The results showed that independent predictors of an unfavorable outcome at discharge were a Glasgow Coma Scale (GCS) score ≤ 8 at 24 hours after operation and pneumonia.
• A study published in 2021 6 compared burr hole surgery with urokinase and craniotomy for acute subdural hematoma. The results showed that age, especially over 65 years, and the absence of basal cistern disappearance were significant factors for safe burr hole surgery.

Considerations for Elderly Patients

• Elderly patients with acute subdural hematoma may have multiple pre-existing conditions, making them more susceptible to complications 6.
• The use of less invasive surgical methods, such as burr hole surgery, may be beneficial for elderly patients with acute subdural hematoma 2, 4, 6.
• The administration of thrombolytic agents, such as r-tPA or urokinase, may be effective in improving outcomes for elderly patients with acute subdural hematoma 3, 6.