What is the recommended management for an elderly patient with a chronic subdural hematoma, particularly those with a history of minor trauma or anticoagulation therapy?

Management of Chronic Subdural Hematoma in Elderly Patients

For elderly patients with chronic subdural hematoma (CSDH), particularly those with minor trauma or on anticoagulation, surgical evacuation via burr hole or subtemporal craniectomy with closed drainage is the definitive treatment, preceded by immediate correction of coagulopathy if present. 1, 2

Initial Assessment and Imaging

• Obtain immediate non-contrast head CT for any elderly patient on anticoagulation with head trauma, regardless of mechanism severity 3
• Document Glasgow Coma Scale (GCS) score with individual components (Eye, Motor, Verbal) and pupillary examination 1
• Verify all anticoagulant and antiplatelet medications, as these dramatically increase hemorrhage risk and expansion 3, 4
• Obtain coagulation studies including PT/INR, aPTT, and anti-Xa levels if on direct oral anticoagulants (DOACs) 5

Admission and Observation Protocol

All patients with documented subdural hematoma require admission regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 1

Monitoring Schedule

• GCS monitoring every 15 minutes for the first 2 hours 1
• Hourly GCS assessments for the following 12 hours 1
• Serial neurological examinations for 24-72 hours 1
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1, 6

Repeat Imaging Timing

• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion 1
• Immediate repeat CT if GCS declines by ≥2 points 1
• Elderly patients on aspirin have 3-fold increased risk of hemorrhage progression (26% vs 9% in non-anticoagulated patients) 1

Coagulopathy Reversal

For Warfarin (Vitamin K Antagonists)

• Administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg intravenous vitamin K immediately 5, 3
• Target INR <1.5 before surgical intervention 5
• Fresh frozen plasma (FFP) should only be used if PCC is unavailable 5
• Do NOT use recombinant factor VIIa (rFVIIa) as first-line reversal agent due to increased thromboembolic risk in elderly 5

For Direct Oral Anticoagulants (DOACs)

• For dabigatran (anti-FIIa): administer idarucizumab 5 g IV; if unavailable, use activated prothrombin complex concentrate (APCC) 50 units/kg IV 5
• For rivaroxaban or apixaban (Factor Xa inhibitors): administer andexanet alfa if available; if unavailable, use prothrombin complex concentrate 5, 3

For Antiplatelet Agents

• Hold aspirin immediately upon diagnosis of subdural hematoma 1
• Anticoagulated patients on concomitant aspirin require particularly cautious management 5

Surgical Indications

Immediate neurosurgical consultation is mandatory for all documented subdural hematomas 1, 6

Critical Thresholds for Surgery

• Subdural hematoma >10 mm thickness 6
• Any midline shift >5 mm 6
• GCS decline of ≥2 points 1
• Development of pupillary changes or posturing indicating herniation 1
• Development of focal neurological deficits indicating mass effect 1
• Failure to show neurological improvement within 72 hours 1

Surgical Technique

• Burr hole(s) with closed drainage is the primary surgical approach for most chronic subdural hematomas 2, 7
• Subtemporal craniectomy with closed drainage may be required for solid or organized hematomas 2
• Surgery should proceed after adequate correction of coagulopathy 2, 7

Postoperative Management

Anticoagulation Resumption

• The decision to restart anticoagulation must weigh thromboembolic risk against recurrence risk 8
• Paradoxically, restarting anticoagulation shows lower recurrence rates (11.1%) compared to not restarting (22.2%), though thromboembolic events occur in 2.2% when restarted 8
• Most recurrences and thromboembolic events occur within first 4 weeks post-surgery 8
• Delay VTE prophylaxis for 24 hours in CNS injuries, then initiate when CT shows no progression 5
• Use LMWH 30 mg every 12 hours (adjust for anti-Xa levels and weight) or UFH 5000 U every 8 hours if renal failure present 5

Recurrence Risk

• Overall recurrence rate is approximately 24% 4
• Anticoagulation/antiplatelet therapy does not significantly increase recurrence rates after adequate pre-surgical preparation 4, 7
• Highest complication rates occur in anticoagulated patients, though not statistically significant 7

Prognostic Factors

Mortality and Outcomes

• For chronic SDH: survival is 87.0% at 30 days, 83.7% at 60 days, and 80.3% at 100 days 9
• Admission GCS score is the most significant predictor of mortality and functional outcome 9
• Age >80 years, contusion volume >10 cm³, SDH volume >50 cm³, and antiplatelet use predict worse discharge functional status 9
• Good outcome (Glasgow Outcome Scale 4-5) achieved in approximately 80-84% of patients regardless of anticoagulation status after adequate management 7

Critical 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
• Avoid hypotension during evaluation; maintain MAP ≥80 mmHg 1, 6
• Do not delay correction of coagulopathy while monitoring 1
• Never assume dizziness or minor symptoms are benign without neuroimaging 6
• Do not independently decide on conservative management if CT shows subdural hematoma—neurosurgical consultation is mandatory 6