What is the best course of action for a patient presenting with increasing confusion, slurred speech, balance issues, weakness, and falls after a subdural hematoma?

Differential Diagnosis and Management of Post-Subdural Hematoma Neurological Deterioration

This patient requires urgent brain MRI to evaluate for subdural hematoma expansion, recurrence, or complications, with immediate neurosurgical consultation if any neurological deterioration is documented. 1

Immediate Diagnostic Priorities

Primary Differential Considerations

Subdural hematoma expansion or recurrence is the most critical diagnosis to exclude, as neurological deterioration following known subdural hematoma demands immediate surgical evaluation. 1 The constellation of confusion, slurred speech, balance issues, weakness, and falls represents significant neurological deficits that indicate either hematoma progression or complications requiring urgent intervention. 1

• Brain MRI with contrast is the preferred imaging modality for subacute evaluation (approximately 3 weeks post-injury), as it is more sensitive than CT for detecting subtle findings, small white matter lesions, and complications adjacent to the calvarium or skull base. 2
• CT head remains valid when rapid assessment is needed for suspected acute changes, particularly if the patient presents with gradual decline suggestive of subacute or chronic subdural hematoma expansion. 2

Secondary Differential Diagnoses

Post-traumatic complications beyond hematoma expansion must be systematically evaluated:

• Cortical spreading depolarization (NESIS): Nonepileptic, stereotypical, and intermittent symptoms can occur after subdural hematoma evacuation, presenting as transient neurological deficits from relative ischemia without epileptic activity. 3 These symptoms may mimic stroke or seizure but show unremarkable electrodiagnostic and radiological findings. 3

• Seizures or post-traumatic epilepsy: While the patient's symptoms could represent post-ictal states, EEG should be obtained if seizure activity is suspected, particularly given the history of subdural hematoma. 2

• Cerebral edema or increased intracranial pressure: Progressive symptoms warrant evaluation for elevated ICP, which significantly impacts outcome (postoperative ICP >45 mmHg correlates with poor prognosis). 4

• Subdural hygroma or effusion: Can develop after hematoma evacuation and cause similar symptoms. 1

Other Important Considerations

Metabolic and systemic causes that can present similarly:

• Hyponatremia: Symptoms are remarkably similar to neurological deterioration and must be checked, as hyponatremia itself can precipitate hepatic encephalopathy-like symptoms. 2
• Hypoglycemia: Can present with confusion, weakness, and altered mental status. 2
• Infection (meningitis/encephalitis): Though typically presents with fever, headache, and stiff neck, these signs may be subtle and require consideration. 2
• Alcohol withdrawal or Wernicke-Korsakoff syndrome: If the patient has alcohol use history, thiamine deficiency can cause confusion, gait disturbances, and eye movement abnormalities. 2

Urgent Management Algorithm

Step 1: Immediate Assessment (Within Hours)

• Obtain vital signs and Glasgow Coma Scale score to establish baseline neurological status. 1
• Perform focused neurological examination including pupillary response, motor strength in all extremities, speech assessment, and gait evaluation. 1
• Check basic metabolic panel including sodium, glucose, and complete blood count. 2

Step 2: Imaging Decision

• If acute deterioration or focal deficits: Obtain stat non-contrast head CT to evaluate for acute hemorrhage expansion, new bleeding, or mass effect. 2, 1
• If subacute progressive symptoms: Brain MRI with contrast is preferred to evaluate for subtle complications, white matter injury, or other post-traumatic sequelae. 2

Step 3: Neurosurgical Consultation Triggers

Immediate neurosurgical consultation is required if: 1

• Any documented neurological deterioration from baseline
• Significant mass effect on imaging
• Decreased level of consciousness
• New or worsening focal deficits
• Hematoma thickness >10mm or midline shift

Step 4: Surgical vs. Conservative Management

• Surgical evacuation is indicated for symptomatic subdural hematoma with significant mass effect, neurological deterioration, or decreased consciousness. 1
• Conservative management with close monitoring is appropriate only for stable patients without significant neurological deficits and small asymptomatic hematomas. 1
• Serial neurological assessments and imaging are mandatory in conservatively managed patients to monitor for progression. 1

Critical Pitfalls to Avoid

• Do not delay surgical intervention when neurological deterioration is documented, as timing directly impacts outcomes. 1, 4
• Do not assume symptoms are "expected post-operative changes" without imaging confirmation, as subdural hematoma can recur or expand. 1
• Do not overlook anticoagulation status: If patient is on anticoagulation, rapid reversal with prothrombin complex concentrate plus vitamin K is required. 1
• Do not miss concurrent spinal CSF leak: If subdural hematoma occurred in context of spontaneous intracranial hypotension, whole spine MRI is needed. 2, 1
• Do not confuse with dementia or psychiatric illness: Chronic subdural hematoma in elderly can present with cognitive decline and neuropsychiatric symptoms including hallucinations, mimicking dementia. 5

Monitoring Requirements

• Regular neurological assessments every 2-4 hours initially if conservative management is chosen. 1
• Maintain euvolemia (avoid hypervolemia which does not improve outcomes). 1
• Serial imaging at 24-48 hours and as clinically indicated. 1
• Fall risk assessment and prevention given the patient's balance issues and weakness, as falls can cause subdural hematoma expansion or new bleeding. 2