What is the next best step in managing a patient with a stable condition and a 10mm thick crescent-shaped subdural hematoma with no midline shift, in addition to holding aspirin (acetylsalicylic acid) and monitoring neurologic status?

Management of Stable Subdural Hematoma in Elderly Patient on Aspirin

This patient requires admission for close neurological monitoring with repeat head CT at 6-8 hours after the initial scan (Option A). 1

Rationale for Repeat Imaging and Observation

Elderly patients on aspirin with documented subdural hematomas cannot be safely discharged, even with normal neurological examinations, due to significant risk of delayed deterioration. 1 The American College of Emergency Physicians specifically recommends that any documented subdural hematoma on CT requires admission regardless of GCS score. 1

Key Risk Factors in This Case

• 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). 1
• The 10mm thickness, while not meeting surgical criteria without midline shift, still represents a significant hemorrhage requiring monitoring. 1
• Most hemorrhage expansion occurs within the first 6 hours, making early repeat imaging critical. 1

Specific Management Protocol

Observation Requirements

• Admit for close neurological observation for 24-72 hours with serial clinical assessments. 1
• Monitor GCS 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. 1
• Any decrease of 2 or more points in GCS score warrants immediate repeat CT scanning. 1

Why Other Options Are Incorrect

Option B (Atorvastatin): Not Indicated

There is no evidence supporting statin administration for acute subdural hematoma management. 1 This represents an inappropriate intervention without guideline support.

Option C (Dexamethasone): Contraindicated

Corticosteroids are not recommended for traumatic brain injury management and may worsen outcomes. 2 The 2018 guidelines on severe TBI management do not support routine corticosteroid use for subdural hematomas.

Option D (Urgent Surgical Evacuation): Not Yet Indicated

Surgical intervention is indicated for subdural hematomas with thickness >5mm AND midline shift >5mm. 3 This patient has a 10mm hematoma but no midline shift, which is the critical determining factor. The patient also has a normal neurological examination (GCS 15), further supporting conservative management with close monitoring rather than immediate surgery. 3

Critical Thresholds for Surgical Intervention

Should any of the following develop during observation, immediate neurosurgical consultation becomes necessary: 1

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

Common Pitfalls to Avoid

• Never discharge patients with documented subdural hematomas based solely on normal neurological examination. 1
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 1
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 4
• Do not delay correction of secondary insults (hypotension, hypoxia) while monitoring. 1

Aspirin Management

Aspirin should be held immediately upon diagnosis of subdural hematoma. 1 The 2023 ACEP guidelines note that while data on aspirin-specific risks in mild TBI are limited, the presence of a documented subdural hematoma changes the risk-benefit calculation significantly. 2 The timing of aspirin resumption should be individualized based on hemorrhage stability on repeat imaging and cardiovascular risk factors, typically not before 7 days. 5