What is the management for a 40-year-old patient with a computed tomography (CT) scan showing a subdural hematoma, presenting with left-sided weakness, confusion, and headache?

Management of Acute Subdural Hematoma with Neurological Deficits

This patient requires urgent neurosurgery consultation with strong consideration for immediate craniotomy. 1

Immediate Actions

Obtain urgent neurosurgery consultation immediately - this is a neurosurgical emergency requiring specialist evaluation within minutes, not hours. 1

• Elevate the head of bed to 30 degrees to reduce intracranial pressure while awaiting neurosurgical evaluation 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to prevent secondary brain injury 2
• Avoid hypotension and hypoxia, which worsen outcomes 2
• Perform immediate non-contrast CT if not already done to confirm diagnosis and assess for other injuries 2

Surgical Decision Algorithm

The decision for urgent craniotomy versus other management depends on specific CT findings and clinical parameters:

Proceed directly to urgent craniotomy if: 1

• Subdural hematoma thickness >10 mm on CT, OR
• Midline shift >5 mm on CT, OR
• Glasgow Coma Scale (GCS) score <9 with any of the following:
  • GCS decreased by ≥2 points from injury to admission
  • Asymmetric or fixed dilated pupils
  • Intracranial pressure >20 mmHg

The presence of left-sided weakness and confusion in this 40-year-old strongly suggests significant mass effect requiring surgical evacuation. 1 These focal neurological deficits indicate the hematoma is causing brain compression and herniation risk.

Surgical Technique

Craniotomy with or without bone flap removal and duraplasty is the standard surgical approach for acute subdural hematoma in patients with GCS <9 or significant neurological deficits. 1

• Decompressive craniectomy (leaving bone flap off) shows better neurological outcomes in patients with GCS ≤8 at admission, particularly after high-energy trauma 3
• Standard craniotomy with bone flap replacement is appropriate for less severe cases 3
• Surgical evacuation should be performed as soon as possible - delays worsen outcomes 1

Alternative Approaches (Only for Specific Scenarios)

Minimally invasive twist-drill craniostomy with fibrinolytic irrigation may be considered only if: 4

• GCS ≥13 (this patient has confusion, likely lower)
• Hematoma thickness ≥7 mm
• Moderate neurological deficits without symptom progression
• No need for immediate evacuation

However, given this patient's left-sided weakness and confusion, they likely do not meet criteria for conservative or minimally invasive management and require urgent craniotomy. 4, 1

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation to obtain additional imaging or laboratory results if the patient is stable for transport 2
• Do not rely on clinical characteristics alone - CT findings must guide surgical decision-making 2
• Do not attempt conservative management in patients with focal neurological deficits suggesting significant mass effect 1
• Intracranial pressure monitoring should be placed in all comatose patients (GCS <9) with acute subdural hematoma 1

Prognosis Considerations

Age >60 years and GCS <8 are associated with higher mortality rates in acute subdural hematoma. 3 This 40-year-old patient has a better baseline prognosis if treated promptly with appropriate surgical intervention.