What is the management approach for an elderly patient with a subacute subdural hematoma, potentially with coagulopathy or on anticoagulant therapy, and a history of falls or trauma?

Management of Subacute Subdural Hematoma

All elderly patients with subacute subdural hematoma require immediate hospital admission with neurosurgical consultation, coagulopathy reversal if anticoagulated, and serial neurological monitoring for 24-72 hours regardless of initial neurological status. 1

Initial Assessment and Imaging

• Obtain immediate non-contrast head CT for any elderly patient with head trauma, particularly those on anticoagulation, regardless of mechanism severity 1
• Document Glasgow Coma Scale (GCS) score with individual components (Eye, Motor, Verbal) and pupillary examination (size and reactivity) at presentation 1, 2
• Verify all anticoagulant medications including warfarin, DOACs (dabigatran, rivaroxaban, apixaban), and antiplatelet agents (aspirin, clopidogrel), as these dramatically increase hemorrhage expansion risk 1, 3
• Obtain coagulation studies immediately: PT/INR, aPTT, platelet count, and anti-Xa levels if DOACs are suspected 4, 1

Mandatory Admission Protocol

Never discharge patients with documented subdural hematomas based solely on normal neurological examination, as delayed deterioration can occur even in neurologically stable patients 1, 2. This is a critical pitfall that must be avoided.

Neurological Monitoring Schedule

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

Repeat Imaging Protocol

• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 2
• Immediate repeat CT if GCS declines by ≥2 points 1, 2
• Repeat CT if any new focal neurological deficits develop 2

Coagulopathy Reversal

The approach differs based on the specific anticoagulant:

For Warfarin (Vitamin K Antagonists)

• Administer 4-factor prothrombin complex concentrate (4F-PCC) at 25-50 IU/kg PLUS 5-10 mg intravenous vitamin K immediately 4, 1, 3
• Target INR <1.5 before any surgical intervention 4, 1
• Fresh frozen plasma (FFP) should only be used if no other treatment is available, as it is inferior to PCC 4
• Do not use recombinant activated factor VII (rFVIIa) as first-line reversal agent 4

For Direct Oral Anticoagulants (DOACs)

• For dabigatran: Administer idarucizumab 5 g IV immediately for life-threatening bleeding with dosable plasma levels 4, 1
• If idarucizumab unavailable: Give activated prothrombin complex concentrates (APCC) 50 units/kg IV 4
• For rivaroxaban or apixaban: Administer andexanet alfa as IV bolus (400 mg over 15 min followed by 480 mg infusion over 2 hours for low dose, or 800 mg over 30 min followed by 960 mg over 2 hours for high dose) 4, 1
• If andexanet alfa unavailable: Give 2000 units of 4F-PCC 4

For Antiplatelet Agents (Aspirin)

• Hold aspirin immediately upon diagnosis of subdural hematoma 2
• Elderly patients on aspirin have 3-fold increased risk of hemorrhage progression (26% vs 9%) 2

Surgical Indications

Immediate neurosurgical consultation is mandatory for all documented subdural hematomas 1. Surgical evacuation is indicated for:

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

Postoperative Management

VTE Prophylaxis Timing

• Delay pharmacological VTE prophylaxis for 24 hours after CNS injury 4, 1
• Initiate prophylaxis only when repeat CT shows no hemorrhage progression 4, 1
• Use LMWH 30 mg every 12 hours (adjust for anti-Xa levels and weight) 4, 1
• In renal failure: Use unfractionated heparin 5000 U every 8 hours 4, 1
• Mechanical prophylaxis (sequential compression devices) should be used when pharmacological prophylaxis is contraindicated 4

Critical Pitfalls to Avoid

• Never discharge patients with documented subdural hematomas regardless of normal examination 1, 2
• Never administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 2
• Never rely on normal vital signs to exclude significant bleeding in elderly patients, as they may have blunted catecholamine responses and cannot mount appropriate tachycardic response 5
• Avoid hypotension during evaluation; maintain MAP ≥80 mmHg continuously 1, 2
• Never assume dizziness or minor symptoms are benign without neuroimaging 1

Special Considerations for Elderly Patients

Elderly patients with subacute subdural hematoma present unique challenges:

• Age ≥70 years is an independent predictor for unfavorable outcome at follow-up (OR 3.1) 6
• Patients with ≥6 comorbidities have significantly worse outcomes (OR 3.1) 6
• Comatose status 24 hours after surgery is the strongest predictor of poor outcome (OR 93.2 at discharge, OR 12.7 at follow-up) 6
• Rebleeding is an independent predictor for unfavorable outcome (OR 9.8 at discharge, OR 3.1 at follow-up) 6

The initial volume and severity determined by GCS score is more predictive of need for surgery than age alone 7. Patients on oral anticoagulants who receive appropriate reversal agents early have comparable rebleeding rates to non-anticoagulated patients 6.