What is the appropriate treatment for a patient with a 1 cm midline subdural hematoma (SDH) with symptom onset 3 days ago?

Management of a 1 cm Midline Subdural Hematoma with 3-Day Symptom Onset

For a patient with a 1 cm midline subdural hematoma with symptom onset 3 days ago, conservative management with close neurological monitoring is recommended, as the hematoma size and midline position do not meet surgical criteria.

Assessment Criteria for SDH Management

The decision between surgical and conservative management depends on several key factors:

Surgical vs. Conservative Management Criteria

• Surgical evacuation is indicated when:

  • SDH thickness >10 mm (1 cm)
  • Midline shift >5 mm
  • GCS score deterioration of ≥2 points
  • Asymmetric or fixed/dilated pupils
  • ICP exceeding 20 mmHg 1

• Conservative management is appropriate when:

  • SDH thickness <10 mm with midline shift <5 mm
  • GCS score of 15 (fully conscious)
  • No neurological deterioration 2

In this case, the patient has a borderline 1 cm (10 mm) hematoma but it is midline with no reported shift, making conservative management the appropriate initial approach.

Conservative Management Protocol

Immediate Actions

1. Close neurological monitoring:

   • Serial neurological examinations (every 1-2 hours initially)
   • Monitor for signs of deterioration including:
     • Decreased level of consciousness
     • New focal neurological deficits
     • Severe headache or vomiting
     • Visual disturbances 3

2. Imaging:

   • Initial CT scan (already performed)
   • Follow-up CT scan within 24 hours to assess stability
   • Additional CT scan before discharge 2

3. Anticoagulation management (if applicable):

   • Immediately discontinue all anticoagulants and antiplatelets
   • Reverse warfarin effect with fresh frozen plasma or prothrombin complex concentrate and vitamin K
   • Reverse heparin with protamine sulfate 4

Ongoing Management

1. Hospital observation for 6-7 days if patient remains stable and fully conscious 2

2. ICP management (if monitored):

   • Maintain ICP <22 mmHg
   • Maintain cerebral perfusion pressure >60 mmHg
   • Maintain MAP 80-110 mmHg 3

3. Thromboprophylaxis:

   • Mechanical thromboprophylaxis with intermittent pneumatic compression initially
   • Consider pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled if platelet count >50×10^9/L 3

Criteria for Surgical Intervention

Immediate surgical evacuation should be performed if any of the following develop:

1. Neurological deterioration:

   • Decrease in GCS score
   • Development of new focal deficits
   • Pupillary abnormalities 1

2. Radiographic progression:

   • Increase in hematoma thickness to >10 mm
   • Development of midline shift >5 mm
   • Signs of increased intracranial pressure 5

If surgery becomes necessary, craniotomy or craniectomy is preferred over burr holes for acute SDH evacuation 3, 5.

Follow-up Care

1. Short-term follow-up:

   • Close follow-up during the first 3-4 weeks after discharge 2
   • Repeat CT scan at 4 weeks to confirm resolution

2. Activity restrictions:

   • Avoid activities that increase intracranial pressure for 4-6 weeks
   • Educate patient about warning signs requiring immediate medical attention:
     • New-onset severe headache
     • Confusion
     • Decreased level of consciousness 3

3. Anticoagulation resumption (if applicable):

   • Wait 3-4 weeks after SDH before restarting anticoagulation
   • Confirm hematoma stability on follow-up imaging 3
   • Consider aspirin 81-100mg daily as first-line antiplatelet therapy when appropriate to restart 3

Pitfalls and Caveats

1. Delayed deterioration can occur even with initially small hematomas, necessitating vigilant monitoring

2. Coagulopathy must be identified and reversed promptly to prevent hematoma expansion

3. Elderly patients may tolerate even small hematomas poorly due to age-related brain atrophy and increased venous fragility

4. Midline hematomas may be bilateral and require careful assessment of both cerebral hemispheres

5. Seizure risk should be considered, though routine prophylactic anticonvulsants are not universally recommended

By following this management protocol, patients with borderline-sized midline SDHs can be safely managed conservatively while maintaining readiness to intervene surgically if clinical or radiographic deterioration occurs.