What is the treatment for a patient with a history of head trauma, presenting with vomiting, tiredness, and altered consciousness, diagnosed with a subdural hematoma on CT (Computed Tomography) scan?

Management of Subdural Hematoma with Altered Consciousness

For a patient with a two-month history of head trauma presenting with vomiting, tiredness, and altered consciousness with a CT showing subdural hematoma, surgical evacuation via craniotomy is the recommended treatment.

Assessment and Decision-Making Algorithm

Clinical Presentation Analysis

• Symptoms of vomiting, tiredness, and altered consciousness following head trauma strongly suggest significant intracranial pathology
• These symptoms indicate increased intracranial pressure and potential mass effect from the subdural hematoma
• Altered consciousness specifically represents a critical deterioration requiring urgent intervention

Treatment Options Based on Guidelines

Craniotomy (Option C)

• Craniotomy is the definitive treatment for symptomatic subdural hematomas with neurological deterioration 1
• The American Heart Association/American Stroke Association guidelines support surgical evacuation for subdural hematomas with:
  • Thickness greater than 5 mm
  • Midline shift greater than 5 mm
  • Neurological deterioration (as evidenced by altered consciousness) 1

Burr Hole (Option B)

• While less invasive than craniotomy, burr hole evacuation is primarily indicated for:
  • Chronic liquefied subdural hematomas
  • Elderly patients with poor surgical candidacy 2
  • Emergency temporizing measure when craniotomy is not immediately available 3

Serial CT (Option A)

• Conservative management with serial CT is appropriate only for:
  • Small acute subdural hematomas (<10 mm thickness)
  • Patients with normal neurological examination (GCS 15)
  • No significant mass effect or midline shift 4
  • This patient's altered consciousness makes this approach inappropriate

Rationale for Craniotomy

1. Neurological Status: The patient's altered consciousness indicates significant brain compression requiring immediate decompression 1

2. Guideline Recommendations: Current guidelines recommend surgical evacuation for symptomatic subdural hematomas, particularly with:

   • Thickness >5 mm with midline shift >5 mm
   • Neurological deterioration (which this patient demonstrates) 1

3. Timing Considerations: While early intervention is preferred, the two-month history suggests this may be a subacute or chronic subdural hematoma with recent deterioration, still requiring definitive treatment 5

4. Surgical Approach: Large craniotomy provides:

   • Complete visualization of the hematoma
   • Ability to address any underlying brain injury
   • Option to perform decompressive craniectomy if brain swelling is encountered 2

Important Considerations

• Preoperative Management:

  • Secure airway and ensure adequate ventilation with end-tidal CO2 monitoring
  • Maintain adequate blood pressure to ensure cerebral perfusion
  • Correct any coagulopathy if present 1

• Surgical Technique:

  • Large craniotomy covering the hematoma
  • Careful attention to dural sinuses and bridging veins
  • Exposure of the floor of the middle cranial fossa when appropriate 2

• Postoperative Care:

  • Close monitoring of intracranial pressure
  • Follow-up CT scan within 24 hours to evaluate for residual hematoma or complications 6
  • Consider antiplatelet therapy resumption only after 4-8 weeks if indicated 6

Common Pitfalls to Avoid

1. Delayed Intervention: Waiting too long when a patient shows neurological deterioration can lead to irreversible brain damage

2. Inadequate Exposure: Small craniotomy may not allow complete evacuation of the hematoma

3. Overlooking Associated Injuries: Failure to identify and address associated brain contusions or vascular injuries

4. Premature Resumption of Anticoagulation: Restarting anticoagulants too early can lead to rebleeding

In conclusion, for this patient with altered consciousness and a subdural hematoma, craniotomy (Option C) is the most appropriate treatment to address the mass effect, relieve intracranial pressure, and provide the best chance for neurological recovery.