How to manage a 65-year-old male patient with a subacute subdural hematoma, stable vitals, and a Glasgow Coma Scale (GCS) score of 15, presenting with numbness of the upper limb and mouth deviation after head trauma two weeks ago?

Management of Subacute Subdural Hematoma with Neurological Deficits

Burr hole evacuation (Option C) is the recommended management for this 65-year-old male patient with a subacute subdural hematoma presenting with neurological deficits (numbness of upper limb and mouth deviation) despite having stable vitals and GCS of 15. 1

Rationale for Surgical Intervention

The presence of neurological deficits in this patient with a subacute subdural hematoma warrants surgical intervention despite the normal GCS score. This recommendation is supported by guidelines from the American Association of Neurological Surgeons 1. The patient's presentation with:

• Neurological deficits (upper limb numbness and mouth deviation)
• Evidence of pressure manifestations
• Confirmed subacute subdural hematoma on CT

These factors clearly indicate the need for evacuation rather than conservative management.

Surgical Options Analysis

Burr Hole Craniostomy (Option C)

• Preferred initial surgical approach for subacute subdural hematomas
• Less invasive than craniotomy
• Associated with good outcomes in most patients
• Allows for evacuation of the hematoma with minimal surgical risk
• Can be performed with closed-system drainage for 2-4 days 2

Craniotomy (Option B)

• More invasive procedure with longer anesthesia time
• Generally reserved for:
  • Recurrent hematomas after burr hole drainage
  • Thick organized hematomas with significant membranes
  • Acute subdural hematomas with significant mass effect 2
• Not the first-line approach for a subacute subdural hematoma in a neurologically stable patient

Why Conservative Management is Inappropriate

Conservative management at home (Option D) is inappropriate for this patient because:

• The patient has developed neurological deficits
• The American College of Emergency Physicians states that observation at home is inappropriate for patients with subdural hematomas who have developed deficits 1
• Even with a GCS of 15, the presence of focal neurological deficits indicates compression of neural structures requiring intervention

Why Hospital Admission Without Immediate Surgery is Insufficient

While admission and workup (Option A) would be appropriate for asymptomatic subdural hematomas or those without significant mass effect, this patient already has:

• Established neurological deficits
• Confirmed subacute subdural hematoma on imaging
• Clear indications for surgical intervention

Post-Surgical Management

After burr hole evacuation:

• Monitor for resolution of neurological symptoms
• Consider intracranial pressure monitoring if preoperative signs of severity were present 1
• Position with head elevation at 20-30° 1
• Close follow-up is essential as recurrent hemorrhages affect 10-20% of patients 3

Common Pitfalls to Avoid

1. Delaying surgical intervention when neurological deficits are present
2. Choosing overly aggressive surgical approaches (craniotomy) when less invasive options are appropriate
3. Underestimating the significance of neurological deficits despite normal GCS
4. Failing to provide adequate post-operative monitoring for potential recurrence

Early intervention when neurological symptoms are present but before severe deterioration occurs is associated with better outcomes in patients with subacute subdural hematomas 1.