What is the next step for a patient with a subdural hematoma (SDH), weakness on the left side, confusion, and a Glasgow Coma Scale (GCS) score of 12-14?

Immediate Neurosurgical Intervention is Indicated

A patient with subdural hematoma presenting with focal neurological deficit (left-sided weakness) and altered mental status (confusion), even with a GCS of 12-14, requires immediate neurosurgical consultation for potential surgical evacuation rather than observation alone. 1

Rationale for Surgical Consultation

Focal Neurological Deficit is an Absolute Indication

• Left-sided weakness represents a focal neurological deficit, which is an absolute indication for neurosurgical evaluation regardless of GCS score. 1
• Focal deficits indicate significant mass effect from the subdural hematoma requiring urgent surgical assessment. 1
• The presence of confusion alongside focal weakness represents progressive neurological deterioration that mandates immediate intervention. 1

GCS Score Does Not Negate Surgical Need

• A GCS score of 12-14 does not define "mild" injury when focal deficits are present—the focal weakness and confusion indicate significant intracranial pathology requiring urgent intervention. 1
• Serial GCS determinations are valuable for monitoring, but a single GCS score is insufficient to determine management when focal deficits exist. 2
• Patients with GCS 9-12 may particularly benefit from early surgical intervention. 2

Evidence Against Observation Alone

• While some minimally symptomatic subdural hematomas with GCS 11-15 can be managed conservatively, this applies only to patients without focal neurological deficits. 3
• Patients managed nonsurgically in successful conservative series had significantly lower incidence of focal deficits (12%) compared to those requiring surgery (40%). 3
• The combination of focal deficit and altered mental status despite preserved GCS indicates ongoing mass effect that observation will not address. 1

Management Algorithm

Immediate Actions

1. Obtain immediate neurosurgical consultation—do not delay for medical management attempts. 1
2. Maintain systolic BP >100 mmHg or MAP >80 mmHg during evaluation. 4
3. Perform urgent brain CT if not already done to characterize hematoma size, thickness, and midline shift. 5

Surgical Decision Criteria

• Hematoma thickness >5mm with midline shift >5mm represents absolute surgical indication. 1
• Progressive neurological deterioration (confusion plus focal weakness) supports surgical evacuation even with smaller hematomas. 1
• GCS motor score ≤5 strongly supports surgical evacuation. 1

Post-Surgical Management

• ICP monitoring is indicated for patients with preoperative focal deficits. 1, 4
• Target cerebral perfusion pressure 60-70 mmHg after ICP monitor placement. 1, 4
• Maintain PaO2 60-100 mmHg and PaCO2 35-40 mmHg. 4

Critical Pitfalls to Avoid

• Never delay neurosurgical consultation to attempt medical management (mannitol, hyperventilation) in patients with focal deficits—these are not substitutes for surgical evaluation. 1
• Do not be falsely reassured by a "preserved" GCS of 12-14 when focal deficits are present—this combination indicates significant pathology. 1
• Serial imaging every 12-24 hours is inappropriate for patients with active focal deficits, as this represents ongoing neurological compromise requiring immediate intervention. 1
• Avoid assuming all subdural hematomas with GCS >11 can be observed—the presence of focal neurological signs changes management completely. 3

Answer: A. Neurological intervention is the correct next step based on the presence of focal neurological deficit and altered mental status, which are absolute indications for neurosurgical evaluation regardless of the GCS score. 1