What are the recommendations for continued monitoring of an 84-year-old patient with a 2mm subdural hematoma?

Monitoring Recommendations for an 84-Year-Old with a 2mm Subdural Hematoma

For an 84-year-old patient with a 2mm subdural hematoma, close neurological monitoring with serial CT scans at 24 hours, 7-10 days, and 30 days is strongly recommended, with immediate repeat imaging for any neurological deterioration.

Initial Assessment and Monitoring Protocol

Immediate Monitoring (First 24-48 Hours)

• Perform frequent neurological evaluations using standardized scales (e.g., Glasgow Coma Scale)
• Monitor for:
  • Changes in level of consciousness
  • New or worsening headache
  • Development of focal neurological deficits
  • Pupillary changes or anisocoria
  • Vomiting or increasing confusion

Imaging Follow-up Schedule

• Repeat CT scan at 24 hours after initial diagnosis 1
• Additional CT scan at 7-10 days 1
• Follow-up imaging at 30 days 1
• Emergency CT scan for any neurological deterioration 1

Risk Stratification and Management

Factors Requiring More Intensive Monitoring

• Anticoagulation use (requires immediate reversal if present) 2
• Age >80 years (associated with poorer outcomes) 3
• Any decline in Glasgow Coma Scale score 1, 3
• Development of new neurological symptoms

Indications for Hospital Admission

• Despite the small size (2mm), given the patient's advanced age (84 years), hospital admission for at least 24 hours of observation is warranted 1
• Patients with small acute subdural hematomas without mass effect may be safely managed conservatively, but require close monitoring 4

Outpatient Follow-up (If Discharged)

Patient/Caregiver Education

• Provide clear instructions about warning signs requiring immediate medical attention:
  • New-onset severe headache
  • Confusion or decreased level of consciousness
  • Weakness or numbness
  • Vision changes
  • Vomiting
  • Seizure activity

Activity Restrictions

• Advise against activities that increase intracranial pressure:
  • Bending, straining, heavy lifting
  • Strenuous exercise
  • Valsalva maneuvers 1

Special Considerations

Anticoagulation Management

• If the patient is on anticoagulants, these should be held
• For patients requiring anticoagulation for high-risk conditions:
  • Wait approximately 4 weeks before restarting anticoagulation 2
  • Obtain follow-up imaging to confirm stability before restarting 2
  • Consider bridging with prophylactic-dose LMWH if thrombotic risk is high 2

Monitoring for Expansion

• Small subdural hematomas can expand, particularly in elderly patients
• Hematomas >10mm thickness have higher likelihood of requiring surgical intervention 4
• Monitor for signs of increased intracranial pressure even with initially small hematomas

Common Pitfalls to Avoid

1. Underestimating risk in elderly patients: Advanced age is associated with poorer outcomes in subdural hematoma 3

2. Inadequate follow-up imaging: Even small subdural hematomas can expand over time, requiring serial imaging

3. Missing subtle neurological changes: Cognitive changes or mild confusion may be the only initial signs of hematoma expansion in elderly patients 5

4. Premature resumption of anticoagulation: Restarting anticoagulation too early significantly increases rebleeding risk 2

By following this monitoring protocol, clinicians can optimize outcomes for elderly patients with small subdural hematomas while minimizing the risk of complications from hematoma expansion.