What is the management for an elderly patient with a subdural hematoma, confusion, mild headache, Glasgow Coma Scale (GCS) 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 likely surgical intervention (Option B), not simple observation or discharge. The combination of subdural hematoma with focal neurological deficit (left-sided weakness) in an elderly patient with altered mental status represents a surgical emergency requiring urgent neurosurgical evaluation. 1, 2, 3

Critical Decision-Making Factors

Why Immediate Neurosurgical Intervention is Required

The presence of focal neurological deficit (left-sided weakness) with a subdural hematoma mandates urgent neurosurgical evaluation regardless of GCS score. 1, 2 The French Society of Anaesthesia provides Grade 1+ (strong) recommendations that focal neurological deficits are high-risk features requiring immediate action in traumatic brain injury patients. 1, 2

• GCS 14 places this patient in the moderate TBI category (GCS 9-13 is moderate, though some classify 14 as mild), but the focal deficit elevates risk substantially 1, 2
• Elderly patients have worse outcomes with subdural hematomas due to brain atrophy creating larger potential subdural space and increased bridging vein vulnerability 1
• Confusion plus focal weakness indicates mass effect requiring surgical consideration 3, 4

Surgical Indications for Acute Subdural Hematoma

Evacuation is generally recommended if clot thickness exceeds 10mm OR midline shift exceeds 5mm, regardless of neurological condition. 3 However, patients with focal neurological deficits warrant surgical consideration even with smaller hematomas. 3, 4

• The presence of focal deficit (left-sided weakness) suggests significant mass effect even if imaging shows <10mm thickness 3
• 91% of patients with high GCS scores (9-15) can achieve functional recovery with appropriate intervention, compared to only 23% with low GCS scores (3-8) 4
• Timing of surgery remains controversial, but the primary brain injury and ability to control intracranial pressure are more critical than absolute surgical timing 5

Why Other Options Are Inappropriate

Option A (Discharge) - Absolutely Contraindicated

Discharge is completely inappropriate for any patient with:

• Documented subdural hematoma on CT 2
• Focal neurological deficit (left-sided weakness) 1, 2
• Altered mental status (confusion) 2
• GCS 14 with intracranial pathology 1

Option C (Admit and Observe 6-12 Hours) - Insufficient

Simple observation without neurosurgical consultation is inadequate because:

• Focal neurological deficits require immediate neurosurgical evaluation, not delayed reassessment 1, 2, 3
• Elderly patients can deteriorate rapidly due to reduced physiological reserve 1
• Any decrease of ≥2 points in GCS or new neurological deficits mandates immediate repeat CT and surgical consideration 2

Option D (ICU and Intubation) - Premature Without Neurosurgical Input

Immediate intubation is not indicated at GCS 14 (intubation threshold is typically GCS ≤8), but this patient does require:

• Immediate neurosurgical consultation 1, 3
• Likely ICU-level monitoring if surgery is performed or if conservative management is chosen 1
• Aggressive prevention of secondary brain injury (maintain SBP >110 mmHg, SpO2 >90%) 1, 2, 6

Specific Management Algorithm

Immediate Actions (Within Minutes)

1. Activate neurosurgical consultation immediately - do not delay for "observation period" 1, 3
2. Maintain systolic blood pressure >110 mmHg (elderly patients may have chronic hypertension; "normal" BP may represent relative hypotension) 1, 2, 6
3. Ensure oxygen saturation >95% to prevent secondary brain injury 2, 6
4. Check coagulation studies immediately (PT, PTT, INR, platelet count) and reverse any coagulopathy 3
5. Perform serial neurological examinations every 15 minutes initially 2

Neurosurgical Decision-Making

The neurosurgeon will determine surgical candidacy based on:

• Hematoma thickness and midline shift on CT (>10mm or >5mm respectively = strong surgical indication) 3
• Clinical trajectory (stable vs. deteriorating) 3, 4
• Patient's baseline functional status and frailty (44% of elderly trauma patients are frail, affecting surgical outcomes) 1

Special Considerations in Elderly Patients

Age alone should not preclude aggressive therapy, but frailty assessment is critical:

• Frailty increases in-hospital complications and adverse discharge disposition 1
• Elderly patients with trauma have 6.8% increased odds of death for each year beyond age 65 1
• However, 83% of patients ≥75 years who survive 4 years post-injury live independently 1

Critical Pitfalls to Avoid

• Never discharge a patient with subdural hematoma and focal neurological deficit, regardless of GCS score 2, 3
• Do not assume "normal" vital signs are reassuring in elderly patients - they may have chronic hypertension making relative hypotension appear normal 1
• Do not delay neurosurgical consultation for a "trial of observation" when focal deficits are present 1, 2, 3
• The combination of hypotension and hypoxemia carries 75% mortality - aggressively prevent secondary brain injury 1, 2