Management of Subacute Subdural Hematoma with Neurological Symptoms
Surgical evacuation via burr hole is the recommended treatment for this 65-year-old male patient with subacute subdural hematoma presenting with neurological deficits.
Clinical Assessment and Decision-Making
The patient presents with:
- Subacute subdural hematoma (2 weeks post-trauma)
- Neurological deficits (upper limb numbness and mouth deviation)
- GCS 15 (fully alert and oriented)
- Stable vital signs
Indications for Surgical Intervention
The presence of neurological deficits (pressure manifestations) in this patient with subacute subdural hematoma warrants surgical intervention, despite the normal GCS score. These symptoms indicate mass effect from the hematoma that requires evacuation to prevent further neurological deterioration.
According to guidelines, surgical intervention is recommended for:
- Patients with symptomatic subdural hematomas causing neurological deficits 1
- Cases where the hematoma is causing clinical evidence of intracranial pressure or significant neurological dysfunction 2
Surgical Options
Burr Hole Evacuation (Option C)
Burr hole evacuation is the preferred treatment for this patient because:
- It is effective for subacute subdural hematomas which are typically more liquefied than acute hematomas 3
- It is less invasive than craniotomy, with lower associated morbidity
- It has shown good outcomes in patients with subacute subdural hematomas 3
Craniotomy (Option B)
Craniotomy would be indicated if:
- The hematoma is acute with significant thickness (>10 mm) 4
- There is substantial midline shift (>5 mm) 4
- The hematoma is solid/organized and not amenable to drainage through burr holes
- There is significant brain compression requiring decompression
In this case, the subacute nature of the hematoma makes it more suitable for burr hole drainage rather than craniotomy.
Why Conservative Management is Not Appropriate
Conservative management (Option D) would be inappropriate because:
- The patient has developed neurological deficits, indicating mass effect
- Studies show that patients with neurological deficits from subdural hematomas require evacuation to prevent further deterioration 2
- Observation at home is considered an "illusion" for patients with subdural hematomas who have developed deficits 1
Why Admission Without Immediate Surgery is Not Appropriate
Admission and workup without immediate surgical intervention (Option A) would delay necessary treatment when the diagnosis is already established. The presence of neurological symptoms indicates the need for prompt surgical decompression 1, 5.
Post-Surgical Management
After burr hole evacuation:
- Monitor for resolution of neurological symptoms
- Consider intracranial pressure monitoring if preoperative signs of severity were present 1
- Ensure proper positioning with head elevation at 20-30° 5
- Monitor for potential reaccumulation of the hematoma
- Provide appropriate seizure prophylaxis 4
Prognosis
With appropriate surgical management via burr hole evacuation, patients with subacute subdural hematomas generally have favorable outcomes:
- Studies report good recovery in the majority of patients with subacute subdural hematomas who undergo surgical evacuation 3
- Early intervention when neurological symptoms are present but before severe deterioration occurs (as in this case with GCS 15) is associated with better outcomes 6
Common Pitfalls to Avoid
- Delaying surgical intervention when neurological deficits are present
- Choosing overly aggressive surgical approaches (craniotomy) when less invasive options (burr holes) would suffice
- Attempting conservative management despite the presence of neurological deficits
- Failing to monitor for reaccumulation of the hematoma post-surgery
In summary, burr hole evacuation is the most appropriate management for this patient with a subacute subdural hematoma presenting with neurological deficits despite preserved consciousness.