What are the next steps in managing a 75-year-old male with a trace acute subdural hemorrhage, history of stroke, recent fall, and hemiplegia?

Management of Acute Subdural Hemorrhage in a 75-Year-Old Post-Stroke Patient

The 75-year-old male with trace acute right posterior parafalcine subdural hemorrhage requires urgent neurosurgical consultation and admission to a neuroscience intensive care unit or stroke unit for close monitoring and management. 1, 2

Initial Assessment and Stabilization

Neurological Monitoring

• Perform frequent neurological assessments using a standardized scale (preferably NIHSS)
• Monitor for signs of deterioration including:
  • Changes in level of consciousness
  • New or worsening focal deficits
  • Pupillary changes
  • Headache severity

Blood Pressure Management

• Maintain systolic blood pressure <160 mmHg but avoid hypotension (systolic <110 mmHg) 2
• Consider arterial line placement for precise BP monitoring in case of deterioration 1
• Use short-acting agents (labetalol) for BP control if needed 1

Coagulation Status

• Immediately determine if patient is on antiplatelet or anticoagulant medications
• If on anticoagulants, urgent reversal is indicated:
  • For warfarin: Prothrombin complex concentrate and vitamin K
  • For DOACs: Specific reversal agents (e.g., idarucizumab for dabigatran) 3
• Hold antiplatelet agents temporarily given the acute hemorrhage 1

Imaging and Monitoring Protocol

Follow-up Imaging

• Repeat head CT in 6-12 hours or sooner if neurological deterioration occurs
• Monitor for hematoma expansion, which can occur within hours to days after initial presentation 4

Risk Factors for Progression

• Pay particular attention to:
  • Initial hematoma volume
  • Degree of midline shift
  • These are independent predictors of hematoma progression requiring surgical intervention 4

Specialized Care Setting

Admission Location

• Admit to a dedicated stroke unit or neuroscience ICU with continuous monitoring 1
• Ensure availability of neurosurgical expertise within 30 minutes 1
• Consider transfer to a comprehensive stroke center if not already at one

Surgical Considerations

Indications for Surgical Intervention

• Current 2mm subdural hemorrhage is small but requires vigilant monitoring
• Indications for urgent surgical evacuation include:
  • Neurological deterioration
  • Hematoma expansion on follow-up imaging
  • Development of significant mass effect or midline shift 2, 5

Surgical Approach

• If surgery becomes necessary, both craniotomy and decompressive craniectomy have similar functional outcomes 5
• The decision between approaches should be made by neurosurgery based on clinical presentation and imaging findings

Post-Stroke Considerations

Rehabilitation Assessment

• Perform formal rehabilitation assessment for existing hemiplegia from previous stroke 1
• Continue appropriate rehabilitation interventions despite the acute hemorrhage
• Implement fall prevention strategies as the patient has multiple risk factors (post-stroke, recent fall) 1

Common Pitfalls to Avoid

• Delayed neurosurgical consultation: Ensure early involvement of neurosurgery team 2
• Inadequate blood pressure control: Both hypertension and hypotension can worsen outcomes 2
• Overlooking coagulopathy: Prompt identification and correction of coagulation abnormalities is essential 2
• Failure to monitor for hematoma expansion: Active bleeding may continue for hours after symptom onset 2, 4
• Inadequate neurological monitoring: Small subdural hematomas can rapidly expand and deteriorate 6

Discharge Planning Considerations

• Early involvement of rehabilitation specialists for post-stroke care
• Address fall prevention strategies before discharge
• Careful consideration of antiplatelet/anticoagulant resumption timing in consultation with neurosurgery and neurology

This patient requires urgent attention due to the combination of acute subdural hemorrhage, history of stroke with hemiplegia, and recent fall. While the current hemorrhage is small, close monitoring and specialized neurological care are essential to prevent deterioration and optimize outcomes.