Can a subdural hematoma in an elderly patient with a Glasgow Coma Scale (GCS) score of 14, confusion, mild headache, left-sided weakness, and a computed tomography (CT) scan showing a subdural hematoma, heal by itself without surgical evacuation?

Can Subdural Hematoma Heal Without Surgical Evacuation?

In an elderly patient with GCS 14, confusion, mild headache, left-sided weakness, and confirmed subdural hematoma on CT, observation without immediate surgical evacuation is appropriate because many subdural hematomas—particularly those with midline shift <10mm and GCS ≥13—can resolve spontaneously or remain stable with close neurological monitoring, reserving surgery only for those who deteriorate. 1, 2, 3

Why Observation is Justified

Natural History of Subdural Hematomas

• Spontaneous resolution occurs in both acute and chronic subdural hematomas, even in cases requiring surgical decompression initially. 4
• A documented case showed complete resolution of a 22mm thick chronic subdural hematoma with 12mm midline shift over 5 months in an 87-year-old woman who refused surgery, with full neurological recovery. 4
• Conservative management succeeded in 31 patients with acute supratentorial subdural hematomas without mortality, though 6 eventually required surgery due to deterioration. 3

Evidence-Based Criteria for Conservative Management

Patients with GCS 14 and focal deficits should be admitted for 24-72 hours of close neurological observation rather than immediate surgery. 1, 2

The specific thresholds for safe observation include:

• Midline shift <10mm on initial CT scan predicts successful conservative management in patients with GCS 15. 3
• Midline shift <5mm is the safer threshold for patients with GCS <15 (like your patient with GCS 14), as larger shifts predict exhaustion of cerebral compensatory mechanisms within 3 days. 3
• GCS 13-15 with reactive pupils indicates preserved brainstem function and potential for observation. 5

Observation Protocol

Neurological Monitoring Schedule

• GCS monitoring every 15 minutes for the first 2 hours, then hourly for 12 hours. 2
• Document individual GCS components (Eye, Motor, Verbal) rather than sum scores, as component profiles predict outcomes better. 2
• Hourly assessment of pupillary size and reactivity, motor strength, and level of confusion/orientation. 1

Repeat Imaging Strategy

• Perform repeat CT at 6 and 24 hours in neurologically stable patients, as hematoma expansion occurs in 26% within the first hour and an additional 12% by 20 hours. 6
• Immediate repeat CT if GCS decreases by ≥2 points or new focal deficits develop. 2

Physiological Management

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 2
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 2
• Avoid long-acting sedatives or paralytics that mask neurological deterioration. 1, 2

When Surgery Becomes Necessary

Absolute Indications for Surgical Evacuation

• Clinical deterioration with GCS decline ≥2 points. 2, 3
• Development of signs of herniation (pupillary changes, posturing). 1, 2
• New or worsening focal neurological deficits indicating increased mass effect. 2
• Failure to show neurological improvement within 72 hours. 2

CT-Based Surgical Criteria

• Midline shift >10mm regardless of hematoma thickness. 5, 3
• Midline shift >5mm in patients with GCS <15 (applicable to your GCS 14 patient). 3
• Midline shift >hematoma thickness with ICP >40 mmHg indicates poor surgical candidacy. 5

Special Considerations in the Elderly

Risk Factors for Deterioration

• Elderly patients on anticoagulation or antiplatelet therapy (including aspirin 81mg daily) have higher risk of delayed acute subdural hematoma, with 70% deteriorating within the first 24 hours. 7
• Delayed hemorrhage occurs in 1.4-4.5% of anticoagulated patients even with initially negative CT, necessitating 24-hour repeat imaging. 6
• Age >60 years independently increases risk of abnormal CT findings and deterioration. 8

Poor Prognostic Indicators

• Bilateral pupillary dilation in comatose patients (GCS 3-8) predicts very high mortality and surgery is not indicated. 5
• Presence of parenchymal contusions and subarachnoid hemorrhage worsens prognosis. 5
• ICP >40 mmHg with midline shift >hematoma thickness indicates surgery will not improve outcome. 5

Critical Pitfalls to Avoid

• Never discharge based solely on "mild" GCS of 14, as the combination of elderly age, confusion, focal weakness, and confirmed subdural hematoma creates unacceptably high risk for deterioration. 1, 2
• Do not delay neurosurgical consultation—obtain it at presentation, not just if deterioration occurs. 2
• Serial GCS assessments provide substantially more valuable information than single determinations, as declining scores indicate poorer prognosis. 2
• Total hospital stay of 6-7 days may suffice for those who become fully conscious, with close follow-up during the first 3-4 weeks. 3