What is the next step in managing a patient with a subdural hemorrhage (SDH) presenting with weakness and confusion but a Glasgow Coma Scale (GCS) score of 12 or 14?

Management of Subdural Hemorrhage with GCS 12-14 and Focal Deficits

The next step is B: Observe with close neurological monitoring and serial imaging every 12-24 hours, rather than immediate neurosurgical intervention. 1

Initial Management Strategy

Hospital admission with intensive neurological observation for 24-72 hours is the recommended approach for patients with subdural hematoma presenting with GCS 12-14 and focal neurological deficits (weakness and confusion). 1 This allows time to assess for clinical deterioration before committing to surgical intervention, which carries significant morbidity in this population.

Key Clinical Decision Points

The decision between observation versus immediate surgery hinges on specific parameters:

• Hematoma thickness ≤10 mm AND midline shift ≤5 mm: These patients can be safely managed conservatively with close monitoring 2, 3, 4
• GCS score stability: A reliable admission GCS that remains stable (not declining by ≥2 points) supports conservative management 2, 3
• Absence of herniation signs: No fixed/dilated pupils, no signs of brainstem compression 3

Observation Protocol

Neurological Monitoring

• Perform hourly neurological assessments focusing on: GCS score, pupillary size and reactivity, motor strength, and level of confusion/orientation 1
• Avoid long-lasting sedatives and paralytic medications that can mask neurological deterioration 1, 2
• Maintain normotension and adequate cerebral perfusion to prevent secondary injury 1

Imaging Schedule

• Repeat CT imaging at 12-24 hour intervals to monitor hematoma evolution 1
• Earlier repeat imaging if any clinical deterioration occurs 2, 4

Indications for Immediate Neurosurgical Consultation

Obtain urgent neurosurgical consultation if any of the following develop:

• Signs of herniation (fixed/dilated pupils, posturing) 1, 3
• New or worsening focal neurological deficits 1
• Decrease in GCS score by ≥2 points from admission 2, 3
• Intracranial pressure >20 mmHg (if ICP monitoring placed) 3

Evidence Supporting Conservative Management

The conservative approach is well-supported for selected patients:

• In patients with GCS 11-15 and small subdural hematomas, 93% achieved functional recovery with nonsurgical management versus 84% with immediate craniotomy 4
• Delayed surgical intervention in elderly patients with monitorable exams resulted in 68% achieving good functional outcomes (GOS 4-5) at 3 months, with only 11% mortality 5
• Patients with stable GCS scores between prehospital and admission assessment (mean 7.3 vs 7.2) were successfully managed conservatively, while those requiring surgery showed significant GCS decline (8.4 to 6.7) 2

Critical Pitfalls to Avoid

• Do not discharge based solely on a "mild" GCS of 12-14: The combination of elderly age (if applicable), confusion, focal weakness, and confirmed subdural hematoma creates high risk for deterioration 1
• Do not rely on hematoma size alone: Clinical examination findings (particularly GCS trajectory) are equally important as CT parameters 2, 4
• Do not use sedating medications unnecessarily: This masks the ability to detect neurological deterioration 1, 2

Surgical Criteria (When Observation Fails)

Proceed to surgical evacuation if:

• Hematoma thickness >10 mm OR midline shift >5 mm regardless of GCS 3
• Clinical deterioration occurs during observation period 1, 2
• Evolving parenchymal hematomas develop on serial imaging 2

The advantage of delayed intervention (when safe) includes smaller surgical incisions, shorter operative times, and decreased anesthetic risk—particularly beneficial in elderly patients 5.