What is the best course of action for an 80-year-old man with a crescent-shaped subdural hematoma, normal neurological examination, and no midline shift, who is currently taking atenolol and low-dose aspirin (acetylsalicylic acid)?

Management of Subdural Hematoma in an Elderly Patient on Low-Dose Aspirin

Neurosurgical consultation is urgently needed for this 80-year-old patient with a 10mm subdural hematoma, as surgical evacuation is the definitive treatment for acute subdural hematomas with significant mass effect. 1

Initial Assessment and Management

The patient presents with:

• 80-year-old man with dizziness and persistent headache
• History of head injury two weeks ago
• Taking atenolol and low-dose aspirin
• CT scan showing 10mm crescent-shaped subdural hematoma
• No midline shift
• Normal neurological examination (GCS 15)

Immediate Actions:

1. Hold aspirin immediately to prevent further bleeding
2. Consult neurosurgery urgently for evaluation and possible surgical intervention
3. Monitor neurological status closely for any deterioration

Rationale for Neurosurgical Consultation

The American Heart Association guidelines clearly state that surgical evacuation via craniotomy or craniectomy is the definitive treatment for acute subdural hematoma with significant mass effect 1. While this patient does not currently show midline shift, the 10mm thickness is significant and requires expert neurosurgical evaluation.

The presence of:

• Significant subdural hematoma thickness (10mm)
• Advanced age (80 years)
• Antiplatelet therapy (aspirin)
• Symptoms (dizziness and persistent headache)

All indicate potential for neurological deterioration and need for surgical intervention.

Management Considerations

Antiplatelet Management:

• Immediate discontinuation of aspirin is necessary
• The American Heart Association recommends withholding antiplatelet therapy in elderly patients with intracranial hemorrhage 1
• Studies show that patients on aspirin therapy have a markedly increased risk of subdural hematoma 2

Surgical vs. Conservative Management:

• Neurosurgeons will evaluate the need for surgical evacuation based on:

  • Hematoma thickness (10mm is significant)
  • Clinical presentation
  • Risk of deterioration

• Surgical options may include:

  • Craniotomy or craniectomy for evacuation 1
  • Burr hole drainage

Monitoring Protocol:

• Close neurological monitoring for:
  • Changes in mental status
  • Development of focal neurological deficits
  • Worsening headache or vomiting
  • Changes in vital signs

Follow-up Care

If managed conservatively after neurosurgical consultation:

• Repeat head CT in 6-8 hours to assess for expansion
• Continue neurological monitoring
• Blood pressure management (target <140/80 mmHg) 1

If surgical intervention is performed:

• Post-operative neurological monitoring
• Repeat imaging to confirm adequate evacuation
• Gradual resumption of activities with restrictions for 4-6 weeks 1

Antiplatelet Resumption Considerations

If aspirin is medically necessary (e.g., for cardiovascular protection):

• Consider resuming 4-8 weeks after stabilization of the hemorrhage 1
• Ensure blood pressure is well-controlled before resumption
• Monitor with follow-up imaging 1-2 weeks after resumption 1

Conclusion

The most appropriate immediate action is to consult neurosurgery urgently while holding aspirin and monitoring neurological status. This approach prioritizes patient safety and addresses the significant subdural hematoma with the expertise needed for optimal management.