Management of Subdural Hematoma with Focal Neurological Deficits
This patient requires immediate neurosurgery consultation with urgent craniotomy for evacuation of the subdural hematoma. 1, 2
Immediate Actions Required
Neurosurgery consultation must be obtained emergently because this patient presents with a symptomatic subdural hematoma manifesting as left-sided weakness and altered mental status (confusion), which are clear indications for surgical intervention. 1, 2
- Urgent craniotomy is indicated for significant acute subdural hematoma with thickness greater than 5 mm and/or midline shift greater than 5 mm, particularly when accompanied by focal neurological deficits. 1
- The combination of focal weakness, confusion, and headache represents symptomatic mass effect requiring surgical decompression to prevent mortality exceeding 40% within 30 days. 2
Concurrent Supportive Measures
While awaiting neurosurgical intervention, implement these critical steps:
Head of bed elevation to 30 degrees should be performed to optimize cerebral venous drainage and reduce intracranial pressure. 1
Intracranial pressure management may require osmotic therapy if signs of herniation develop:
- Mannitol 0.25 to 2 g/kg IV over 30-60 minutes can be administered for acute neurological deterioration while preparing for surgery. 3
- Monitor for signs of increased intracranial pressure including worsening confusion, pupillary changes, or posturing. 1
Why Surgery Cannot Be Delayed
The presence of focal neurological deficits (left-sided weakness) indicates significant mass effect requiring immediate surgical evacuation rather than conservative management. 4, 5
- Symptomatic subdural hematomas presenting with focal deficits have poor outcomes with nonsurgical management, even when the hematoma appears stable on imaging. 4
- Delayed intervention in symptomatic patients can lead to cerebral ischemia, prolonged neurological recovery, and increased mortality. 4, 6
Critical Pitfall to Avoid
Do not delay surgery for "observation" in a patient with focal neurological deficits. While some small, asymptomatic subdural hematomas can be managed conservatively, the presence of weakness and confusion represents symptomatic mass effect that will not resolve without surgical evacuation. 4, 5
- The extent of underlying brain injury and ability to control intracranial pressure are critical determinants of outcome, making early surgical intervention essential. 6
- Patients presenting with focal deficits who undergo delayed surgery have significantly worse functional recovery compared to those treated urgently. 6
Answer to the Question
B. Neurosurgery consultation is the correct immediate answer, which will lead directly to A. Urgent craniotomy for definitive treatment. 1, 2
C. Head elevation should be implemented as a supportive measure but is insufficient as the primary intervention for a symptomatic subdural hematoma with focal deficits. 1