How should a neurologically intact adult with a 2 mm acute subdural hematoma along the right tentorial fold and no coagulopathy be managed?

Management of 2mm Acute Tentorial Subdural Hematoma

A neurologically intact adult with a 2mm acute subdural hematoma along the right tentorial fold should be managed conservatively with close neurological observation, as this small, minimally symptomatic hematoma does not meet criteria for surgical intervention. 1

Conservative Management Strategy

Initial Assessment and Monitoring

• Neurological status must be documented using Glasgow Coma Scale (GCS) and focal neurological examination to establish baseline function, as patients with GCS 11-15 and minimal symptoms are appropriate candidates for non-surgical management 1
• Serial neurological evaluations should be performed at least every 4 hours initially to detect any deterioration that would necessitate intervention 2
• Imaging should assess for mass effect, midline shift, and cisternal compression, as these findings would alter management even with small hematomas 1

Observation Protocol

• Close monitoring is mandatory even for small tentorial subdural hematomas, as rare cases can enlarge and require delayed surgical evacuation 3
• Follow-up CT imaging should be obtained if any neurological deterioration occurs, as tentorial hematomas can gradually enlarge despite initially small volume 3
• Patients should be observed for at least 24 hours with regular vital sign monitoring and maintenance of systolic blood pressure >100 mmHg 2

Rationale for Conservative Management

Evidence Supporting Non-Surgical Approach

• 93% of minimally symptomatic acute subdural hematoma patients managed non-surgically achieved functional recovery in a series of 83 patients with GCS 11-15 1
• Patients managed without surgery had significantly better outcomes when hematomas were ≤1 cm thick with open cisterns (90% vs 28% with open cisterns in surgical group) 1
• There appears to be no advantage in evacuating clots unless causing clinical evidence of intracranial hypertension or significant neurological dysfunction 1

Surgical Indications to Monitor For

Surgery would be indicated if the patient develops:

• Altered consciousness or neurological deterioration (GCS decline or new focal deficits) 4
• Significant mass effect with midline shift >5mm on imaging 4
• Hematoma thickness increasing to >5mm with associated symptoms 4
• Signs of increased intracranial pressure (altered consciousness, vomiting, progressive headache) 4

Important Caveats

Risk Factors Requiring Enhanced Vigilance

• Antiplatelet or anticoagulant therapy increases risk of hematoma expansion and should be documented 4
• Advanced age and higher Injury Severity Score are significantly associated with worse outcomes 1
• Approximately 6% of conservatively managed patients may develop chronic subdural hematoma requiring delayed craniotomy 1

Tentorial Location Considerations

• Tentorial subdural hematomas generally pose no serious clinical threats and rarely require surgical intervention compared to convexity locations 3
• However, even tentorial hematomas may ultimately deteriorate, as demonstrated by rare cases showing considerable enlargement with midline shift requiring emergency evacuation 3
• The tentorial location does not eliminate the need for vigilant observation, as one case report documented a patient deteriorating from alert to stuporous within 24 hours despite initially small volume 3

Management Algorithm Summary

For this 2mm tentorial acute subdural hematoma:

1. Admit for observation with serial neurological assessments every 4 hours 2
2. Maintain blood pressure >100 mmHg systolic 2
3. Obtain repeat CT if any clinical deterioration occurs 3
4. Continue conservative management if patient remains neurologically intact with no mass effect 1
5. Proceed to surgical evacuation only if deterioration develops 4, 3