What is the initial management for a patient presenting with confusion, headache, and left-sided weakness with a CT scan showing a subdural hematoma?

Initial Management of Subdural Hematoma with Neurological Deficits

For a patient presenting with confusion, headache, and left-sided weakness with CT-confirmed subdural hematoma, the answer is B - Urgent craniotomy (or burr hole drainage) is the appropriate initial management. 1

Critical Diagnostic Clarification

There is an important discrepancy in your question: a biconcave collection describes an epidural hematoma, NOT a subdural hematoma (subdural hematomas are crescent-shaped). However, I will address subdural hematoma management as stated in your expanded question.

Immediate Surgical Intervention Required

Burr hole drainage is the preferred first-line surgical treatment for symptomatic chronic subdural hematomas presenting with altered consciousness and neurological deficits. 1 The American College of Surgeons recommends burr hole evacuation as first-line treatment for symptomatic chronic subdural hematomas. 1

Key Indications for Surgery:

• Altered mental status (confusion) 1
• Focal neurological deficits (left-sided weakness) 1
• Symptomatic presentation requiring immediate intervention 1

Why Other Options Are Incorrect

Head Elevation and Monitoring (Option A):

• Delaying surgical intervention in symptomatic patients with altered consciousness leads to neurological deterioration and poorer outcomes 1, 2
• Conservative management is only appropriate when no signs of intracranial hypertension or neurological deterioration exist 2
• This patient has clear neurological deficits, making observation inappropriate

Dexamethasone (Option C):

• Corticosteroids should never be used for brain swelling management in traumatic brain injury 2
• No role in subdural hematoma management

Observation Alone (Option D):

• Inappropriate given symptomatic presentation with neurological deficits 1
• Reserved only for asymptomatic or minimally symptomatic patients without mass effect

Surgical Approach Algorithm

For chronic subdural hematoma:

• First-line: Burr hole drainage 1
• Consider subdural drain placement during surgery to reduce recurrence rates 1

For acute-on-chronic subdural hematoma:

• Craniotomy reserved for cases with solid components 1
• Emergency decompressive craniotomy if severe (GCS ≤4) 3

Critical Perioperative Management

Blood Pressure Targets:

• Maintain systolic BP >100 mmHg or MAP >80 mmHg for adequate cerebral perfusion 4, 2
• Maintain euvolemia and avoid hypovolemia 1, 4

Coagulation Management:

• Verify anticoagulant/antiplatelet use immediately 2
• Maintain platelet count >50,000/mm³ 2
• Maintain PT/aPTT <1.5 times normal control 2

Common Pitfalls to Avoid

• Never delay surgery in symptomatic patients - this is the single most critical error leading to poor outcomes 1, 2
• Never use corticosteroids for subdural hematoma management 2
• Never induce hypervolemia postoperatively - it does not improve outcomes and may cause complications 1
• Patients on anticoagulants require special consideration for medication reversal prior to intervention 1, 2

Post-Operative Monitoring

• Monitor for complications including seizures 1
• Serial neurological assessments with continuous GCS monitoring 2
• Repeat CT imaging if neurological deterioration occurs 2