What is the next step in managing an elderly patient with a stable condition and a 10mm thick crescent-shaped subdural hematoma, with no midline shift, after holding aspirin and monitoring neurologic status?

Management of Stable Elderly Patient with 10mm Subdural Hematoma on Aspirin

Repeat head CT six to eight hours after the initial scan (Option A) is the appropriate next step for this elderly patient with a 10mm subdural hematoma, stable neurologic examination, and recent aspirin use.

Rationale for Repeat Imaging

This patient requires admission with serial neurological monitoring and repeat CT imaging based on several critical factors:

• Any documented subdural hematoma on CT requires admission regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 1
• Elderly patients (≥65 years) on aspirin with subdural hematomas have a 3-fold increased risk of hemorrhage progression (26% vs 9% in non-anticoagulated patients) 2
• Patients with subdural hematomas should not be discharged, even with normal examinations, due to risk of delayed deterioration requiring neurosurgery 1

Specific Management Protocol

Observation Period

• Admit for close neurological observation for 24-72 hours with serial clinical assessments 1
• Perform GCS monitoring every 15 minutes for the first 2 hours, then hourly for the following 12 hours 1
• Document individual GCS components (Eye, Motor, Verbal) and pupillary size/reactivity at each evaluation 1

Repeat Imaging Timing

• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 2
• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning 1

Why Other Options Are Incorrect

Option B (Atorvastatin):

• No evidence supports statin administration for acute subdural hematoma management 3

Option C (Dexamethasone):

• Corticosteroids are not indicated for traumatic subdural hematomas and may worsen outcomes 3

Option D (Urgent Surgical Evacuation):

• This patient does not meet criteria for urgent surgery: GCS is 15, no midline shift, no focal deficits, and no signs of herniation 1
• Surgical intervention is indicated only for clinical deterioration with GCS decline ≥2 points or development of focal neurological deficits 1

Critical Thresholds for Surgical Intervention

• Development of pupillary changes or posturing indicating herniation 1
• GCS decline of ≥2 points 1
• Development of focal neurological deficits indicating mass effect 1
• Failure to show neurological improvement within 72 hours 1

Special Considerations for Subdural Hematomas

• In low-risk mild TBI patients with subdural hematomas, obtaining outpatient follow-up head CT is reasonable to monitor for resolution, as 7 patients in one study had unchanged or expanded hemorrhage on outpatient imaging 4
• Five of 12 patients requiring craniotomy for subdural hematomas remained asymptomatic before surgery, emphasizing the importance of repeat imaging regardless of clinical examination 5

Common Pitfalls to Avoid

• Discharging patients with documented subdural hematomas based solely on normal neurological examination 1
• Administering long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 1
• Failing to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1
• Delaying correction of secondary insults (hypotension, hypoxia) while monitoring 1