What is the treatment for a patient with a subdural (subdural hematoma) hematoma, presenting with vomiting, tiredness, and an affected level of consciousness, two months after head trauma, confirmed by computed tomography (CT) scan?

Management of Subdural Hematoma with Neurological Deterioration

Craniotomy (option C) is the definitive treatment for a patient with subdural hematoma presenting with vomiting, tiredness, and altered consciousness two months after head trauma. 1

Clinical Assessment and Indications for Surgery

The patient's presentation with:

• Vomiting
• Tiredness
• Affected level of consciousness
• Two-month history of head trauma
• CT confirmation of subdural hematoma

These symptoms strongly suggest a chronic subdural hematoma with significant mass effect causing increased intracranial pressure, which requires urgent surgical intervention. The altered consciousness specifically represents critical deterioration requiring immediate decompression. 1

Surgical Management Options

Craniotomy (Recommended)

Craniotomy is the preferred treatment for this patient because:

• It provides complete visualization of the hematoma
• Allows thorough evacuation of organized/chronic blood products
• Enables addressing any underlying brain injury
• Offers the option to perform decompressive procedures if brain swelling is encountered 1
• Most appropriate for chronic subdural hematomas (>2 weeks old) which often have organized blood products requiring direct visualization 2

Burr Hole Surgery

• While burr hole drainage is often used for acute or subacute subdural hematomas, it is less effective for chronic subdural hematomas with organized blood products
• The patient's altered consciousness indicates significant mass effect, which may require the more extensive exposure provided by craniotomy 2

Serial CT Monitoring

• Serial CT monitoring without surgical intervention is inappropriate for patients with neurological deterioration
• A study by Wilberger et al. found that non-operative management is only appropriate for small acute subdural hematomas in conscious patients without mass effect 3
• The patient's symptoms of vomiting and altered consciousness indicate active mass effect requiring intervention

Evidence-Based Decision Making

Current guidelines recommend surgical evacuation for:

• Symptomatic subdural hematomas with neurological deterioration (which this patient demonstrates) 1
• Subdural hematomas with thickness >10 mm or midline shift >5 mm 2
• Patients with decreased level of consciousness 2

A key study by Bullock et al. established that subdural hematomas with thickness >10 mm or midline shift >5 mm should be surgically evacuated regardless of GCS score, with craniotomy being the preferred approach for chronic collections 2

Timing of Intervention

Urgent surgical intervention is critical in patients with neurological deterioration. While the timing from injury to surgery is less critical in chronic subdural hematomas than in acute ones, the development of neurological symptoms indicates a need for prompt intervention to prevent further deterioration. 4

Postoperative Management

• Close monitoring of neurological status
• Follow-up CT scan within 24 hours to evaluate for residual hematoma
• Management of intracranial pressure if elevated
• Gradual mobilization as tolerated

Common Pitfalls to Avoid

1. Delaying surgical intervention in patients with neurological deterioration
2. Choosing burr hole drainage for chronic subdural hematomas with organized blood products
3. Attempting conservative management in patients with significant mass effect and altered consciousness
4. Failing to address potential underlying coagulopathy before surgery

In conclusion, craniotomy is the most appropriate treatment for this patient with a chronic subdural hematoma presenting with neurological deterioration, as it provides the best opportunity for complete evacuation of organized blood products and addressing any underlying brain injury.