Management of Subdural Hemorrhage with GCS 12-14
For a patient with subdural hemorrhage and GCS 12-14 who is confused, the next step is hospital admission with close neurological observation and serial imaging, NOT immediate neurosurgical intervention. 1
Initial Management Strategy
Admit to a monitored setting for serial neurological assessments rather than proceeding directly to surgery or discharging the patient. 1 The British Journal of Anaesthesia specifically recommends hospital admission with close neurological observation for 24-72 hours for patients with mild-to-moderate traumatic brain injury indicated by a GCS score of 14 with focal deficits. 1
Observation Protocol
Perform hourly neurological assessments focusing on Glasgow Coma Scale score, pupillary size and reactivity, motor strength, and level of confusion/orientation to monitor for potential deterioration. 1
Maintain normotension and adequate cerebral perfusion, avoiding long-lasting sedatives and paralytic medications that can mask neurological deterioration. 1
Serial CT imaging should be performed based on clinical trajectory, with repeat scans if neurological status changes. 2
When to Escalate to Neurosurgical Intervention
Obtain immediate neurosurgical consultation if:
- Signs of herniation develop 1
- New focal neurological deficits appear 1
- GCS score decreases by 2 or more points 3
- Intracranial pressure exceeds 20 mm Hg (if ICP monitoring placed) 3
Evidence Supporting Conservative Management
Research demonstrates that patients with acute subdural hematoma and GCS scores of 11-15 can safely be managed without craniotomy unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction. 4 In one study, 93% of patients managed nonsurgically achieved functional recovery compared with 84% of those undergoing craniotomy. 4
Critical CT parameters for conservative management:
- Hematoma thickness ≤10 mm 3
- Midline shift ≤5 mm 3
- For patients with GCS <15, a midline shift >5 mm predicts exhaustion of cerebral compensatory mechanisms within 3 days and typically requires surgical intervention 5
Common Pitfalls to Avoid
Do not discharge patients based solely on a "mild" GCS of 12-14. The combination of confusion, confirmed subdural hematoma, and this GCS range creates high risk for deterioration. 1 One study documented that patients who deteriorated showed a statistically significant decline in GCS score between prehospital determination and admission assessment (mean GCS 8.4 to 6.7), emphasizing the importance of serial monitoring. 6
Avoid long-lasting sedatives and paralytic medications before definitive assessment, as these mask neurological deterioration and prevent accurate GCS scoring. 6, 1
Monitoring Duration
A total hospital stay of 6-7 days may suffice for those who become fully conscious, with repeat CT studies before discharge and close follow-up during the first 3-4 weeks. 5 Most deterioration occurs within the first 24-72 hours, making this the critical observation window. 1