What is the management for an elderly patient with confusion, mild headache, left side weakness, and a Glasgow Coma Scale (GCS) score of 13, diagnosed with a subdural hematoma on computed tomography (CT) scan after a traumatic accident?

Management of Elderly Patient with Subdural Hematoma, GCS 13, and Focal Neurological Deficit

This patient requires immediate hospital admission to a monitored setting with serial neurological assessments and neurosurgical consultation (Option C or D, with ICU preferred given the focal deficit), not discharge or immediate surgery. 1, 2

Rationale for Admission Over Discharge or Immediate Surgery

Patients with documented subdural hematoma on CT require admission regardless of GCS score, as delayed deterioration can occur even in those appearing stable initially. 1 The combination of elderly age, confusion, focal weakness (left-sided), and confirmed subdural hematoma creates high risk for deterioration that absolutely precludes discharge. 2

• Approximately 1 in 4 patients with mild traumatic brain injury (GCS 13-15) and abnormal neurological findings will require treatment, making admission mandatory. 1
• Nearly one-quarter of patients with initial GCS 13-15 experience two-point or more deterioration while still in the emergency department. 3
• The mortality rate for acute subdural hematoma ranges from 60-66%, with GCS score being the strongest predictor of outcome. 4, 5

Observation Protocol: 24-72 Hours with Serial Assessments

The British Journal of Anaesthesia recommends admission with close neurological observation for 24-72 hours rather than immediate surgery for patients with GCS 14 and focal deficits. 1, 2 This patient's GCS of 13 with focal weakness falls into this category requiring intensive monitoring.

Specific Monitoring Parameters

• Perform GCS monitoring every 15 minutes for the first 2 hours, then hourly for 12 hours. 1
• Document individual GCS components (Eye, Motor, Verbal) rather than sum scores, as component profiles predict outcomes. 1
• Assess pupillary size and reactivity at each evaluation—these are critical prognostic indicators. 1
• Monitor for focal neurological deficits and level of confusion/orientation hourly. 2

Critical Thresholds for Intervention

A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning and neurosurgical consultation. 1 This is the most important threshold to monitor, as:

• ED neurologic deterioration is associated with 1-week mortality, 30-day mortality, and poor neurologic outcomes. 3
• Development of new focal neurological deficits or signs of herniation (pupillary changes) indicates need for surgical evacuation. 1, 2

ICU vs. General Admission Decision

ICU admission is appropriate for this patient given the combination of GCS 13, focal deficit, and elderly status, though intubation is not immediately indicated if airway is protected. 1

• The American Society of Anesthesiologists suggests ICU admission with intubation is premature for GCS 14 patients who can protect their airway, unless there is herniation or rapidly deteriorating status. 1
• However, this patient's GCS of 13 (lower than 14) with focal weakness justifies ICU-level monitoring.
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 1, 6
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 1

Neurosurgical Consultation Timing

Obtain immediate neurosurgical consultation at presentation, not just if deterioration occurs. 2 The presence of subdural hematoma with focal deficit requires neurosurgical awareness from the outset.

Indications for Surgical Evacuation

• Clinical deterioration with GCS decline ≥2 points. 1
• Development of additional focal neurological deficits indicating mass effect. 1
• Signs of herniation (pupillary changes, posturing). 1
• Failure to show neurological improvement within 72 hours. 1

Critical Pitfalls to Avoid

Never administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 1, 2 This is one of the most common and dangerous errors.

• Do not discharge based solely on "mild" GCS of 13-14—the combination of elderly age, confusion, focal weakness, and confirmed subdural hematoma creates unacceptably high risk. 2
• Do not delay correction of secondary insults (hypotension, hypoxia) while waiting to prognosticate. 1
• Do not make irreversible decisions before 72 hours unless brain death criteria are met or clear clinical deterioration occurs. 1
• Serial GCS assessments provide substantially more valuable information than single determinations—declining scores indicate poorer prognosis. 1

Prognostic Factors

The most important predictors of poor outcome in this patient include:

• GCS score: Patients with GCS 13 have intermediate mortality; 91% with GCS 9-15 achieve functional recovery vs. 23% with GCS 3-8. 4
• Age: Elderly patients (>61 years) have 73% mortality compared to 64% for ages 21-40. 4
• Pupillary reactivity: 97% mortality with bilateral unreactive pupils, 81% with unilateral. 4
• Focal deficits: Left-sided weakness indicates significant mass effect or underlying brain injury. 7

Why Not Immediate Surgery?

The extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome; therefore, controlling ICP through observation is more critical than absolute timing of subdural blood removal. 5 Time from injury to operative evacuation was not statistically significant for outcome in severely head-injured patients, even when examined at hourly intervals. 5

Answer: C (Admit and observe) or D (ICU admission)—with ICU preferred given GCS 13 and focal deficit. Not B (immediate surgery) unless deterioration occurs, and definitely not A (discharge).