What is the recommended management approach for a patient with a subdural hematoma (SDH) two weeks after head trauma?

Management of Subdural Hematoma Two Weeks After Head Trauma

For a patient with a subdural hematoma two weeks after head trauma, surgical evacuation is recommended for significant hematomas (thickness >5mm with midline shift >5mm), while conservative management with close neurological monitoring is appropriate for patients with minimal hematomas and stable neurological status. 1, 2

Assessment and Imaging

• Perform a complete neurological assessment using Glasgow Coma Scale (GCS), pupillary size and reactivity, and motor responses
• Obtain a brain CT scan to evaluate:
  • Hematoma thickness (critical threshold: >5mm)
  • Midline shift (critical threshold: >5mm)
  • Mass effect on surrounding structures
  • Presence of other intracranial injuries

Management Algorithm

Surgical Management Indications

Immediate surgical evacuation is indicated if:

• Hematoma thickness >5mm with midline shift >5mm 1
• Neurological deterioration regardless of hematoma size
• Signs of increased intracranial pressure despite medical management
• Acute hydrocephalus

Conservative Management

Consider conservative management if:

• Patient is neurologically intact or minimally symptomatic
• Hematoma is small (<5mm thickness) with minimal midline shift
• No signs of increased intracranial pressure
• No progression on serial imaging

Conservative Management Protocol

1. Neurological Monitoring

   • Regular neurological assessments to detect early deterioration
   • Serial CT imaging to monitor hematoma size and mass effect

2. Blood Pressure Management

   • Maintain systolic blood pressure >110 mmHg 1, 2
   • Maintain mean arterial pressure >80 mmHg in patients with traumatic brain injury 1, 2
   • Avoid hypotension which significantly increases morbidity and mortality

3. Intracranial Pressure Management

   • Head elevation at 20-30° to improve venous drainage 2
   • Adequate sedation and analgesia if needed
   • Consider external ventricular drainage for persistent intracranial hypertension 1

4. Prevention of Complications

   • DVT prophylaxis
   • Seizure prophylaxis
   • Maintain normothermia
   • Glycemic control

Important Considerations

• Risk factors for delayed hematoma enlargement: Initial hematoma volume and degree of midline shift are independent predictors of the need for delayed surgical intervention 3
• Monitoring period: Patients should be monitored closely for at least 2-3 weeks, as hematoma progression can occur during this time 3, 4
• Spontaneous resolution: Some subdural hematomas may resolve spontaneously, particularly in younger patients with good neurological status 5, 6

Caution and Pitfalls

• Avoid hypotonic solutions like Ringer's lactate in patients with head trauma 1
• Do not delay surgical intervention if neurological deterioration occurs
• Be aware that seemingly stable hematomas can enlarge over time, requiring delayed surgical evacuation in approximately 35% of initially non-operative cases 3
• Patients on anticoagulants or antiplatelets require more vigilant monitoring as they have higher risk of hematoma expansion
• Elderly patients and those with brain atrophy may tolerate larger hematomas but still require close monitoring