What is the recommended management for an elderly patient with a subdural hematoma, Glasgow Coma Scale (GCS) 14, confusion, and mild headache after an accident?

Management of Elderly Patient with Subdural Hematoma and GCS 14

This patient requires admission with close neurological observation for 24-72 hours with serial clinical assessments and repeat imaging, not immediate surgery or discharge. 1, 2

Rationale for Admission and Observation (Answer C)

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

Why Not Immediate Surgery (Option B)?

• Conservative management is appropriate for minimally symptomatic subdural hematomas with GCS 11-15. 3
• Approximately 74% of acute subdural hematomas are initially managed non-surgically, with 93% achieving functional recovery. 3
• Only 6.5% of conservatively managed subdural hematomas eventually require delayed surgery, with median delay of 9.5 days. 4
• Immediate surgery is reserved for patients with clinical evidence of intracranial hypertension or significant neurologic dysfunction, which this patient does not yet demonstrate beyond mild confusion. 3

Why Not Discharge (Option A)?

• Any patient with documented subdural hematoma on CT requires admission regardless of GCS, as delayed deterioration can occur. 1
• The elderly population has higher risk for progression due to cerebral atrophy allowing more space for hematoma expansion. 4
• Even with negative initial CT scans in anticoagulated patients, observation periods of 24 hours are recommended—this patient already has a visible hematoma. 1

Why Not Immediate ICU/Intubation (Option D)?

• GCS 14 does not meet criteria for intubation (typically reserved for GCS ≤8 or inability to protect airway). 2
• The patient can be managed on a monitored floor or step-down unit with serial neurological assessments rather than requiring ICU-level care initially. 1

Specific Management Protocol

Initial Assessment Period (First 24-72 Hours)

Serial GCS monitoring is the cornerstone of management:

• Every 15 minutes for the first 2 hours, then hourly for the following 12 hours per Scandinavian protocols. 5
• Document individual GCS components (Eye, Motor, Verbal) rather than just sum scores, as component profiles predict outcomes. 5
• Assess pupillary size and reactivity at each evaluation, as these are key prognostic indicators. 5

Critical threshold for intervention:

• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning. 5
• Failure to show neurological improvement within 72 hours is a negative prognostic factor requiring reassessment of management strategy. 2

Physiological Targets During Observation

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 2
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 2
• Correct any confounding factors including sedating medications, alcohol, or metabolic derangements. 1

Indications for Surgical Intervention

Proceed to neurosurgical evacuation if:

• Clinical deterioration with GCS decline of ≥2 points. 5
• Development of focal neurological deficits indicating mass effect. 6, 3
• Signs of intracranial hypertension (worsening headache, vomiting, altered consciousness). 3
• Radiographic progression on repeat imaging showing increased thickness or midline shift. 4, 7

Radiographic Risk Factors for Deterioration

Monitor closely if the subdural hematoma demonstrates:

• Maximum thickness >10 mm (mean thickness requiring surgery is 17.1 mm vs 7.5 mm for conservative management). 8, 7
• Midline shift >5 mm (mean shift requiring surgery is 12.8 mm vs 4.7 mm for conservative management). 8, 7
• Location at the convexity (associated with higher deterioration rates). 4

Critical Pitfalls to Avoid

• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 8
• Do not make irreversible decisions before 72 hours unless brain death criteria are met or there is clear clinical deterioration. 2
• Do not rely on a single GCS determination—serial assessments provide substantially more valuable clinical information, with declining scores indicating poorer prognosis. 5, 8
• Do not delay correction of secondary insults (hypotension, hypoxia) while waiting to prognosticate. 2

Expected Outcomes with Conservative Management

• 76.7% of conservatively managed patients achieve good outcomes. 4
• 66.7% of initially conservatively treated patients reach functional outcomes, compared to 84% with immediate craniotomy. 3, 8
• The key is identifying the 6.5% who will deteriorate and require delayed intervention through vigilant monitoring. 4