What is the management for an elderly patient with a subdural hematoma, confusion, mild headache, Glasgow Coma Scale (GCS) score of 14, and left-sided weakness after an accident?

Management of Elderly Patient with Subdural Hematoma, GCS 14, and Focal Neurological Deficit

This patient requires immediate neurosurgical consultation and admission to a monitored setting (ICU or neurosurgical step-down unit) with close neurological observation, not immediate surgery in most cases, but readiness for urgent intervention if deterioration occurs. 1, 2

Rationale for This Approach

Why Not Immediate Surgery (Option B)?

• The presence of left-sided weakness with GCS 14 indicates a moderate TBI with focal neurological deficit, but this alone does not mandate immediate craniotomy. 1 The decision for surgical intervention depends on multiple factors including hematoma size, midline shift, and rate of neurological deterioration.

• Research shows that in acute subdural hematoma, the extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome, and the ability to control intracranial pressure is more critical than the absolute timing of subdural blood removal. 3

• Patients with GCS scores of 13-15 (mild TBI) who have focal neurological deficits require brain CT scanning and close monitoring, but not automatic surgical intervention. 1

Why Not Simple Observation for 6-12 Hours (Option C)?

• This timeframe is insufficient. Guidelines recommend serial neurological examinations every 15 minutes during the first 2 hours, then hourly for at least 4-12 hours, with the occurrence of secondary neurological deficit or a decrease of at least two points in GCS requiring repeat CT scan. 1

• The presence of focal weakness (left-sided) already indicates significant mass effect or underlying brain injury requiring more intensive monitoring than standard observation. 1

Why Not Routine Discharge (Option A)?

• Absolutely contraindicated. Any patient with intracranial hemorrhage on CT and focal neurological deficit requires admission. 1

Why Not Routine Intubation (Option D)?

• Intubation is reserved for severe TBI (GCS ≤8) or patients unable to protect their airway. 1 This patient has GCS 14, which does not meet criteria for prophylactic intubation.

Specific Management Algorithm

Immediate Actions (First Hour):

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion, as arterial hypotension is associated with significantly increased morbidity and mortality. 1

• Ensure oxygen saturation >90% as hypoxemia is associated with increased mortality and worse neurological outcomes. 1

• Obtain detailed history regarding anticoagulation or antiplatelet therapy, as these significantly affect management and prognosis. 1

Monitoring Strategy:

• Admit to ICU or neurosurgical step-down unit with capability for hourly neurological assessments. 2, 4

• Serial neurological examinations should include:

  • Glasgow Coma Scale scoring
  • Pupillary examination (bilateral unreactive pupils carry 97% mortality, unilateral unreactive 81% mortality) 5
  • Motor examination focusing on the focal deficit (left-sided weakness)
  • 1, 2

• ICP monitoring is NOT routinely indicated for this patient (GCS 14 with subdural hematoma) unless neurological surveillance becomes unreliable, hemodynamic instability develops, or imaging shows compressed basal cisterns. 2, 4

Repeat Imaging Indications:

• Obtain repeat CT scan if:

  • Neurological deterioration occurs (decrease in GCS ≥2 points)
  • New or worsening focal deficits develop
  • Development of altered consciousness beyond baseline
  • 1, 4

• Routine repeat imaging at 12-24 hours may be considered given the presence of focal deficit, though recent evidence suggests this may not be necessary in all mild TBI patients with small hemorrhages. 6

Surgical Intervention Criteria:

Immediate neurosurgical intervention is indicated if:

• Progressive neurological deterioration despite medical management 1, 2
• Significant midline shift (>5mm) with mass effect 4
• Signs of herniation (pupillary changes, posturing, rapid GCS decline) 1, 2

Medical Management:

• Reverse any coagulopathy immediately if patient is anticoagulated. 1

• Maintain cerebral perfusion pressure 60-70 mmHg if ICP monitoring is placed. 2, 4

• Osmotic therapy (mannitol 0.25-2 g/kg or hypertonic saline) should be available for acute neurological deterioration while awaiting potential neurosurgical intervention. 7, 8

Critical Prognostic Factors

This patient has several concerning features:

• Age (elderly): Patients over 61 years have 73% mortality with acute subdural hematoma 5
• Focal neurological deficit: Indicates significant mass effect or underlying brain injury 1
• GCS 14: While in the "mild TBI" range, the presence of focal deficit elevates risk 1

However, favorable factors include:

• GCS >8 (91% of patients with GCS 9-15 achieve functional recovery vs. 23% with GCS 3-8) 5
• No pupillary abnormalities mentioned 5

Common Pitfalls to Avoid

• Do not delay neurosurgical consultation while waiting to "see how the patient does" - early involvement is critical even if immediate surgery is not needed. 1, 2

• Do not assume stability based on initial GCS alone - the focal deficit indicates significant pathology requiring vigilant monitoring. 1

• Do not discharge or observe in a non-monitored setting - any intracranial hemorrhage with neurological deficit requires intensive monitoring capability. 1

• Do not routinely intubate based solely on presence of subdural hematoma - reserve for GCS ≤8 or inability to protect airway. 1

The correct answer is C (Admit and observe), but with critical modifications: admission must be to ICU or monitored neurosurgical unit with immediate neurosurgical consultation, not simple observation for 6-12 hours, but rather continuous monitoring with readiness for urgent intervention.