What's the next step in managing a patient with a stable subdural hematoma and no significant mass effect or midline shift on CT scan, who's on low-dose daily aspirin (acetylsalicylic acid)?

Management of Stable Subdural Hematoma in Patient on Aspirin

For this neurologically stable patient with a 10mm subdural hematoma, no midline shift, and GCS 15, you should repeat head CT six to eight hours after the initial scan (Option A) while continuing to hold aspirin and monitor neurologic status closely.

Rationale for Repeat Imaging

Patients on antiplatelet therapy with documented subdural hematomas have a 3-fold increased risk of hemorrhage progression (26% vs 9% in non-anticoagulated patients), making repeat imaging essential even when neurologically stable. 1, 2

• The American College of Emergency Physicians guidelines specifically note that elderly patients (≥65 years) on low-dose aspirin with subdural hematomas require closer monitoring due to increased bleeding risk 1
• Any documented subdural hematoma on CT requires admission regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 2
• Most hemorrhage expansion occurs within the first 6 hours after onset, making the 6-8 hour timeframe optimal for detecting clinically significant progression 3, 2

Why Not the Other Options

Atorvastatin (Option B) has no role in acute subdural hematoma management and is not supported by any guideline for this indication. 1

Dexamethasone (Option C) is not indicated for subdural hematomas. Corticosteroids have no established benefit in traumatic intracranial hemorrhage and may increase infection risk. 2

Urgent surgical evacuation (Option D) is not indicated at this time because the patient lacks surgical criteria: he is neurologically intact (GCS 15), has no midline shift, and the hematoma is only 10mm thick. 2

Specific Management Protocol

Observation Period

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

Repeat Imaging Timing

• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion 3, 2
• If any neurological deterioration occurs (GCS decline ≥2 points), obtain immediate repeat CT scanning 2

Aspirin Management

• Continue holding aspirin during the observation period 1
• The low incidence of delayed intracranial hemorrhage does not strongly support withholding aspirin indefinitely, but in the acute setting with documented hemorrhage, temporary discontinuation is prudent 1
• Reassess the risk/benefit ratio of restarting aspirin after demonstrating stability on repeat imaging 1, 4

Critical Thresholds for Neurosurgical Intervention

Immediate neurosurgical consultation is warranted if any of the following develop: 2, 4

• GCS decline of ≥2 points
• Development of pupillary changes or posturing indicating herniation
• Development of focal neurological deficits indicating mass effect
• Significant hemorrhage expansion on repeat CT (>25% volume increase or development of midline shift)
• Failure to show neurological improvement within 72 hours

Common Pitfalls to Avoid

• Do not discharge this patient based solely on normal neurological examination – documented subdural hematomas require admission and repeat imaging regardless of clinical stability 2
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation – this masks clinical deterioration 2
• Do not assume the patient is safe for discharge after a single negative CT – antiplatelet therapy significantly increases the risk of delayed hemorrhage progression 1, 2
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2
• Provide clear discharge instructions (after appropriate observation period) that include symptoms of delayed hemorrhage and when to return immediately 1, 3