What is the best course of treatment for an elderly patient with a history of trauma and a subdural hematoma, possibly with underlying bleeding disorders or anticoagulant use, presenting with signs of increased intracranial pressure and severe symptoms?

Management of Subdural Hematoma in Elderly Trauma Patients

For an elderly patient with subdural hematoma following trauma, presenting with signs of increased intracranial pressure and severe symptoms, urgent neurosurgical consultation and intervention is required immediately after stabilization of life-threatening hemorrhage. 1

Immediate Priorities

Hemodynamic Stabilization First

• Control any life-threatening systemic hemorrhage before addressing the intracranial pathology 1
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions 1
• Target cerebral perfusion pressure ≥60 mmHg if ICP monitoring is established 1, 2

Urgent Neurological Assessment

• Perform immediate neurological evaluation including Glasgow Coma Scale motor score and pupillary examination 1
• Obtain non-contrast head CT scan to characterize hematoma size, location, mass effect, and midline shift 3
• Verify anticoagulant or antiplatelet use, as these dramatically increase expansion risk 3

Surgical Indications

Immediate Surgical Evacuation Required When:

• Subdural hematoma thickness >5 mm with midline shift >5 mm 1, 4
• Any symptomatic subdural hematoma causing neurological deterioration 1
• Signs of cerebral herniation or severe intracranial hypertension 1
• GCS score ≤8 with significant mass effect 1

Critical caveat: If both epidural and subdural hematomas coexist, evacuate the epidural first regardless of which appears larger, as epidurals expand more rapidly and cause acute herniation due to anatomic confinement by suture lines 4

Coagulopathy Reversal (Essential Before Surgery)

Target Parameters Before Neurosurgery:

• Platelet count >50,000/mm³ minimum; higher values advisable for craniotomy 1
• PT/aPTT <1.5 times normal control 1
• Use point-of-care testing (TEG/ROTEM) if available to optimize coagulation 1
• Reverse anticoagulation emergently in consultation with neurosurgery 3

Surgical Timing Considerations

Age-Specific Mortality Data:

The presenting GCS is the strongest predictor of mortality, not surgical timing per se 5, 6. In elderly patients (≥65 years):

• GCS 13-15: 8-15% mortality 5
• GCS 9-12: ~36% mortality 5
• GCS 3-8: approaching 60% mortality, especially age ≥85 5

Important nuance: While older literature emphasized 4-hour surgical windows, more recent evidence shows the extent of primary brain injury and ability to control ICP matters more than absolute timing of clot removal 6. However, this does NOT justify delay in symptomatic patients with mass effect.

Alternative Approach for Stable Elderly Patients:

For patients >55 years with low-energy trauma, GCS ≥13, and stable neurological examination despite meeting size criteria (>10 mm thickness or >5 mm midline shift), delayed burr hole evacuation (≥48 hours) shows significantly fewer major complications (RR 2.33) and minor complications (RR 2.42) compared to immediate craniotomy 7. This applies ONLY to neurologically stable patients who can be monitored intensively.

Intraoperative Management

Anesthetic Considerations:

• Maintain PaO₂ 60-100 mmHg 1
• Maintain PaCO₂ 35-40 mmHg 1
• Avoid hypocapnia except temporarily for acute herniation 1
• Transfuse RBCs for hemoglobin <7 g/dL; consider higher threshold in elderly with cardiovascular disease 1

Osmotherapy for Herniation:

• Use mannitol 0.25-2 g/kg IV as 15-25% solution over 30-60 minutes for acute intracranial pressure reduction 8
• In small/debilitated elderly patients, use 500 mg/kg 8
• Contraindicated in severe dehydration, anuria, or pulmonary edema 8

Postoperative Management

ICP Monitoring Indications:

• All comatose patients at risk for intracranial hypertension after hemorrhage control 1
• Patients with compressed basal cisterns or mass effect on imaging 2
• When neurological surveillance is not feasible 2

Target Parameters:

• Maintain CPP 60-70 mmHg 4, 2
• Avoid hypocapnia-induced cerebral vasoconstriction 4
• Monitor for hematoma re-accumulation with serial neurological exams 3
• Consider repeat CT at 24 hours, especially in anticoagulated patients 3

External Ventricular Drainage:

• Consider for persistent intracranial hypertension despite sedation and correction of secondary insults 1
• Small CSF volume removal can markedly reduce ICP 1

Special Elderly Considerations

Increased Vulnerability:

• Elderly patients have increased risk of bridging vein tears due to brain atrophy 5
• Small hematomas can expand rapidly, especially with anticoagulation 3, 4
• Maintain euvolemia to optimize cerebral perfusion; avoid hypovolemia 3

Prognostic Factors Beyond Age:

• Presence of subarachnoid hemorrhage increases mortality (OR 2.86) 5
• Midline shift >5 mm increases mortality (OR 2.40) 5
• Postoperative ICP >45 mmHg strongly correlates with poor outcome 6

Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic patients with mass effect while awaiting "optimal" timing 1
• Do not perform non-emergent extracranial surgery in the presence of intracranial hypertension 1
• Do not use 4% albumin in severe TBI patients (increased mortality RR 1.62) 1
• Do not underestimate small hematomas in anticoagulated elderly patients—they expand rapidly 3, 4
• Do not prioritize subdural over epidural when both present—epidurals herniate faster 4