What is the best management approach for an elderly patient with a subdural hematoma, confusion, left-sided weakness, and a Glasgow Coma Scale (GCS) score of 14 after an accident?

Management of Elderly Patient with Subdural Hematoma, GCS 14, Confusion, and Left-Sided Weakness

This patient requires hospital admission with close neurological observation for 24-72 hours, not immediate neurosurgical intervention, as the GCS score of 14 with focal deficits indicates mild-to-moderate traumatic brain injury that necessitates monitoring for potential deterioration before determining surgical necessity. 1

Initial Management Approach

Admit to monitored setting (step-down unit or ICU depending on institutional protocols) for serial neurological assessments. 1 The key management principle is physiological stabilization while allowing time for observation and monitoring, rather than rushing to surgery or discharging the patient. 1

Why Not Immediate Surgery?

• The presence of subdural hematoma alone does not mandate immediate neurosurgical intervention. 2 Studies demonstrate that subdural hematomas with thickness ≤10 mm and midline shift ≤5 mm can often be managed nonoperatively with excellent outcomes (66.7% functional recovery in conservatively managed cases). 2
• The critical determinant for surgery is clinical deterioration, not simply the presence of blood on CT. 2, 3 A GCS of 14 with stable vital signs warrants observation first. 1
• In severe head injury cases (GCS 3-7), the extent of underlying brain injury is more important than the subdural clot itself in dictating outcome, and the ability to control intracranial pressure is more critical than absolute timing of blood removal. 3

Why Not Discharge?

• Any patient with an intracranial hemorrhage on CT requires admission, regardless of GCS score. 1 Multiple studies show that 14-22% of patients with GCS 14 have abnormal CT findings, and approximately 3-4% require neurosurgery. 1
• Elderly patients are at significantly higher risk for delayed deterioration. 4 In one case series, a 75-year-old patient with initial GCS 15 and negative CT deteriorated to GCS 6 within 24 hours with development of acute subdural hematoma. 4
• 70% of neurological deterioration in delayed subdural hematomas occurs within the first 24 hours. 4

Observation Protocol (24-72 Hours)

Serial Clinical Monitoring

Perform hourly neurological assessments focusing on:

• Glasgow Coma Scale score (the most critical observation parameter) 1, 2
• Pupillary size and reactivity 1
• Motor strength in all extremities (particularly monitoring the existing left-sided weakness) 1
• Level of confusion/orientation 1

Document any change in GCS score between initial assessment and subsequent evaluations, as deteriorating GCS is the strongest predictor of need for surgical intervention. 2 In surgical cases, mean GCS dropped from 8.4 to 6.7, while conservatively managed patients maintained stable scores (7.3 to 7.2). 2

Exclude Confounders

Before attributing clinical status solely to the subdural hematoma, ensure you have addressed: 1

• Medications (sedatives, analgesics, any administered drugs)
• Seizure activity
• Physiological derangement (hypotension, hypoxemia, hypercapnia)
• Metabolic abnormalities

Supportive Care

• Maintain normotension and adequate cerebral perfusion 1
• Mechanical ventilation if needed for airway protection (though not routinely indicated for GCS 14) 1
• Avoid long-lasting sedatives and paralytic medications, as these mask neurological deterioration. 2

Indications for Neurosurgical Consultation During Observation

Obtain immediate neurosurgical consultation if:

• GCS score decreases by ≥2 points 2
• Development of new focal neurological deficits 1
• Signs of herniation (pupillary changes, posturing, Cushing's triad) 1
• Repeat CT shows hematoma expansion or increased midline shift 2

When to Consider Surgical Intervention

Surgery becomes indicated when: 2

• Hematoma thickness >10 mm with midline shift >5 mm 2
• Clinical deterioration despite medical management 1, 2
• Signs of increased intracranial pressure refractory to medical therapy 1

Common Pitfalls to Avoid

• Do not discharge based solely on "mild" GCS of 14. 1 The combination of elderly age, confusion, focal weakness, and confirmed subdural hematoma creates high risk for deterioration. 4
• Do not rush to surgery without observation period unless there are clear signs of herniation or massive hematoma. 2, 3 Nonoperative management for selected cases is at least as safe as surgical management when properly monitored. 2
• Do not rely on initial CT findings alone. 4 Delayed acute subdural hematomas can develop even after negative initial imaging, particularly in elderly patients on antiplatelet agents. 4
• Do not administer long-acting sedatives or paralytics during the observation period. 2 These medications prevent detection of clinical deterioration, which is the most reliable indicator for surgical need. 2

Answer to Multiple Choice Question

The correct answer is C: Admit and observe for 6 to 12 hours and reassess (though the observation period should extend to 24-72 hours based on current evidence). 1, 2, 4