Management of Stable 10mm Subdural Hematoma After Holding Aspirin
You should consult neurosurgery for surgical evaluation and consideration of burr hole drainage, as this patient has a symptomatic subdural hematoma (presenting with dizziness and headache) measuring 10mm, which meets criteria for intervention despite the absence of midline shift. 1
Rationale for Neurosurgical Consultation
Symptomatic subdural hematomas require surgical consideration regardless of size when patients present with neurological symptoms. 1 This patient's presentation with dizziness and headache two weeks post-trauma, combined with a 10mm subdural hematoma, indicates a symptomatic lesion requiring specialist evaluation.
The 2023 consensus guidelines specifically state that "symptomatic haematomas with significant mass effect may need burr hole drainage," and while this patient lacks midline shift, the presence of symptoms (dizziness, headache) combined with the hematoma size warrants surgical assessment 1
The patient's antiplatelet therapy (aspirin) increases bleeding risk and complicates management, making neurosurgical input essential for determining optimal timing and approach 2, 3, 4
Why Other Options Are Inadequate
Repeat CT scanning alone (options a and b) is insufficient for a symptomatic patient with a 10mm subdural hematoma:
Repeat imaging at 6-8 hours is primarily indicated for anticoagulated patients with minor head injury and negative initial CT scans to exclude delayed hemorrhage 1
This patient already has a documented 10mm subdural hematoma with symptoms—the clinical question is not whether hemorrhage exists, but whether surgical intervention is needed 1
Atorvastatin (option b) has no established role in acute subdural hematoma management and is not mentioned in any guideline for this indication 1, 5
Dexamethasone (option c) is not indicated for traumatic subdural hematoma management and does not appear in contemporary guidelines for this condition 1, 5
Critical Management Points After Holding Aspirin
Antiplatelet reversal considerations:
Aspirin was appropriately held, but the patient remains at risk for hematoma expansion for several days due to the 7-10 day lifespan of affected platelets 2, 3
If surgical intervention is planned, consider desmopressin 0.4 μg/kg, tranexamic acid 1-2g, and platelet transfusion (2 units) to optimize hemostasis 3
Monitoring requirements pending neurosurgical evaluation:
Serial neurological examinations are essential, as clinical deterioration may occur despite initial stability 1, 3
The patient's history of TIA and hypertension increases stroke risk, making careful blood pressure management critical—maintain adequate cerebral perfusion (MAP >65-70 mmHg) while avoiding hypertension that could worsen bleeding 5
Common Pitfalls to Avoid
Do not assume that absence of midline shift equals absence of surgical indication. Symptomatic subdural hematomas require neurosurgical assessment regardless of mass effect on imaging 1
Do not delay neurosurgical consultation for repeat imaging in a symptomatic patient with documented subdural hematoma. The imaging has already established the diagnosis; the next step is determining treatment 1, 3
Do not restart aspirin without neurosurgical clearance, as this patient has both cardiovascular disease (TIA history) requiring antiplatelet therapy and active intracranial hemorrhage—timing of reinitiation requires specialist input balancing thrombotic and hemorrhagic risks 2, 3, 4