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 consciousness level
• History of head trauma two months prior
• CT confirmation of subdural hematoma

These symptoms strongly suggest a chronic subdural hematoma with significant mass effect causing increased intracranial pressure and neurological deterioration, which requires urgent surgical intervention.

Treatment Options Analysis

1. Serial CT (Option A)

• Serial CT monitoring without intervention is inappropriate for patients with neurological deterioration
• This approach is only suitable for:
  • Small acute subdural hematomas (<10mm thickness) 2
  • Patients with normal neurological examination 3
  • Absence of mass effect on imaging 2

2. Burr Hole (Option B)

• Burr hole drainage is primarily indicated for:
  • Liquefied chronic subdural hematomas without significant mass effect 2
  • Cases without significant neurological deterioration
  • When rapid access to craniotomy is not available as a temporizing measure 4

3. Craniotomy (Option C)

• Craniotomy is the definitive treatment for:
  • Subdural hematomas with neurological deterioration (as in this case) 1
  • Hematomas >10mm thick or with midline shift >5mm 3
  • Cases with altered consciousness level 1, 3

Evidence-Based Decision Making

The American Heart Association/American Stroke Association guidelines support surgical evacuation via craniotomy for subdural hematomas with:

• Thickness greater than 5-10mm
• Midline shift greater than 5mm
• Neurological deterioration (as evidenced by altered consciousness) 1

Bullock et al. established that patients with acute subdural hematoma and decreased level of consciousness should undergo surgical evacuation via craniotomy, especially when the GCS score has decreased between the time of injury and hospital admission 3.

Surgical Approach Considerations

Craniotomy offers several advantages over burr hole drainage in this scenario:

• Complete visualization of the hematoma
• Ability to address any underlying brain injury
• Option to perform decompressive craniectomy if brain swelling is encountered 1
• More effective for hematomas that may have both liquid and solid components, as often seen in subacute/chronic cases

Timing of Intervention

While the timing from injury to surgery has been debated, the presence of neurological deterioration (altered consciousness) necessitates urgent intervention regardless of the chronicity of the hematoma 5. The patient's symptoms indicate progressive neurological decline, which requires immediate surgical decompression rather than observation or less invasive measures.

Post-Surgical Management

Following craniotomy:

• Close monitoring of intracranial pressure
• Follow-up CT scan within 24 hours to evaluate for residual hematoma
• Careful monitoring of neurological status
• Consideration of seizure prophylaxis

In summary, for a patient with subdural hematoma presenting with vomiting, tiredness, and altered consciousness two months after head trauma, craniotomy (option C) is the most appropriate treatment to effectively evacuate the hematoma, address the mass effect, and improve neurological outcomes.