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 a two-month-old subdural hematoma presenting with vomiting, tiredness, and altered consciousness, as these symptoms indicate significant neurological deterioration requiring complete surgical evacuation. 1

Clinical Assessment and Indications for Surgery

The patient's presentation with:

• Vomiting
• Tiredness
• Altered level of consciousness
• Two-month history of head trauma
• Confirmed subdural hematoma on CT

These symptoms strongly suggest increased intracranial pressure and mass effect from the subdural hematoma, indicating urgent surgical intervention is needed 1. This clinical picture represents a chronic subdural hematoma with acute deterioration, which carries significant mortality and morbidity risks if not properly managed.

Treatment Options Analysis

Option A: Serial CT

• Not appropriate for a patient with active neurological deterioration
• Serial CT monitoring is only suitable for:
  • Asymptomatic patients
  • Small hematomas (<5mm thickness)
  • No midline shift
  • Neurologically intact patients 2

Option B: Burr Hole

• While burr hole drainage can be effective for liquefied chronic subdural hematomas without significant mass effect
• Not optimal for patients with:
  • Altered consciousness
  • Active neurological deterioration
  • Potential for mixed density or organized hematoma components 3

Option C: Craniotomy

• Indicated when patients show:
  • Neurological deterioration (altered consciousness)
  • Symptoms of increased intracranial pressure (vomiting, tiredness)
  • Subdural hematoma with significant mass effect 1, 3
• Provides complete visualization and evacuation of the hematoma
• Allows addressing any underlying brain injury
• Enables decompressive measures if brain swelling is encountered 1

Evidence-Based Recommendation

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

Neurosurgical guidelines specifically recommend that patients with subdural hematomas who present with GCS score decreases or altered consciousness should undergo surgical evacuation via craniotomy 3. This is particularly important for patients with chronic subdural hematomas who develop acute neurological deterioration.

Perioperative Considerations

• Preoperative:

  • Secure airway if consciousness is severely impaired
  • Maintain adequate blood pressure to ensure cerebral perfusion
  • Correct any coagulopathy if present

• Postoperative:

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

While timing of surgery for acute subdural hematomas has been debated 4, the presence of neurological deterioration in this case makes urgent intervention necessary regardless of the two-month interval since the initial trauma.