How to manage a patient with a stable condition and a Glasgow Coma Scale (GCS) of 15, presenting with neurological symptoms, including numbness of the upper limb and mouth deviation, after being diagnosed with a subacute subdural hematoma following a head trauma?

Management of Subacute Subdural Hematoma in a Stable Patient with Neurological Symptoms

Surgical evacuation via burr hole drainage is the recommended management for this patient with a subacute subdural hematoma presenting with neurological symptoms (upper limb numbness and mouth deviation) despite stable vital signs and GCS of 15.

Clinical Assessment and Decision-Making

• The patient presents with neurological deficits (upper limb numbness and mouth deviation) which indicate pressure effects from the subacute subdural hematoma, despite having a GCS of 15 1
• These focal neurological deficits are significant indicators for surgical intervention, even with a preserved level of consciousness 2
• The presence of "pressure manifestation" symptoms suggests that the hematoma is causing significant mass effect requiring intervention 1

Surgical Management Options

• Burr hole drainage is the preferred surgical approach for subacute subdural hematomas with neurological symptoms but stable GCS 3
• This minimally invasive technique is particularly effective for subacute hematomas (2 weeks old in this case) where the blood collection has begun to liquefy, making it amenable to drainage through burr holes 3
• Craniotomy would be indicated if the hematoma was acute with significant thickness (>10mm), midline shift (>5mm), or if the patient had a deteriorating GCS score 2

Evidence Supporting Surgical Intervention

• Patients with neurological deficits from subdural hematomas require surgical evacuation to prevent further deterioration and improve outcomes 2, 4
• Even in patients with GCS 15, the presence of focal neurological deficits (like the upper limb numbness and mouth deviation in this case) is a strong indication for surgical intervention 2
• Minimal trephination with closed-system drainage (burr hole) has shown excellent results in managing expanding subacute subdural hematomas with neurological symptoms 3

Rationale Against Conservative Management

• Conservative management is appropriate only for patients without significant neurological deficits and minimal mass effect 5, 4
• This patient already demonstrates pressure symptoms (numbness and mouth deviation), indicating that conservative management alone would be inadequate 1
• Waiting for further deterioration before intervention could lead to worse outcomes and increased morbidity 1, 2

Monitoring and Post-Procedure Care

• After surgical evacuation, close neurological monitoring is essential to detect any changes in the patient's condition 1
• Cerebral perfusion pressure should be maintained between 60-70 mmHg to ensure adequate cerebral blood flow 6
• Serial neurological examinations should be performed to detect any secondary deterioration 1

Common Pitfalls to Avoid

• Delaying surgical intervention in patients with neurological deficits can lead to worse outcomes, even if the GCS is preserved 2, 4
• Overestimating the safety of conservative management when focal neurological deficits are present 5, 4
• Failing to recognize that subacute subdural hematomas (4-21 days old) may expand and require intervention, particularly in patients over 60 years of age 3

Burr hole drainage provides the optimal balance of effective treatment with minimal surgical invasiveness for this stable but symptomatic patient with a subacute subdural hematoma 3.