What is the recommended medical management for an adult patient who is neurologically intact with a 2 mm acute subdural hematoma on the right tentorial fold and no coagulopathy or anticoagulant use?

Medical Management of Neurologically Intact Adult with 2mm Acute Tentorial Subdural Hematoma

For a neurologically intact adult patient with a 2mm acute subdural hematoma on the right tentorial fold without coagulopathy or anticoagulant use, admission for close neurological observation with serial clinical assessments is recommended, with repeat head CT at 6-8 hours to assess for hemorrhage expansion. 1

Initial Management Protocol

Admission and Observation Requirements

• Any documented subdural hematoma on CT requires admission, regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 1
• Patients should undergo GCS monitoring every 15 minutes for the first 2 hours, then hourly for the following 12 hours 1
• Individual GCS components (Eye, Motor, Verbal) and pupillary size/reactivity should be documented at each evaluation 1
• The observation period should be 24-72 hours with serial clinical assessments 1

Repeat Imaging Strategy

• Repeat head CT should be obtained at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 1, 2
• Although this is a small (2mm) tentorial subdural hematoma, even tentorial SDH may ultimately deteriorate and enlarge, forcing surgical evacuation 3
• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning 1
• Patients with initial SDH size >3mm have risk factors for expansion that warrant hospital-based monitoring 4

Risk Stratification

Factors Associated with Hematoma Expansion

• Larger initial SDH size, concurrent subarachnoid hemorrhage, hypertension, convexity location, and midline shift are significantly associated with hematoma expansion 4
• Approximately 30-40% of intracranial hemorrhages enlarge during the first 12-36 hours 5
• While no patient with an initial SDH ≤3mm required surgery in one study, 11.1% of these small hematomas did enlarge (maximum width 10mm) 4
• Tentorial subdural hematomas, though generally posing no serious clinical threats, can gradually enlarge and eventually require surgical evacuation 3

Critical Thresholds for Surgical Intervention

• Development of pupillary changes or posturing indicating herniation is a critical threshold for surgical intervention 1
• GCS decline of ≥2 points is a critical threshold for surgical intervention 1
• Development of focal neurological deficits indicating mass effect is a critical threshold for surgical intervention 1
• Failure to show neurological improvement within 72 hours is a critical threshold for surgical intervention 1
• An acute SDH with thickness >10mm or midline shift >5mm on CT should be surgically evacuated, regardless of GCS score 6

Hemodynamic Management

• Mean arterial pressure should be maintained ≥80 mmHg to ensure adequate cerebral perfusion 1
• Correction of secondary insults (hypotension, hypoxia) should not be delayed while monitoring 1

Medications to Avoid

• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 1
• Corticosteroids such as dexamethasone are not recommended for traumatic brain injury management and may worsen outcomes 1

Common Pitfalls to Avoid

• Discharging patients with documented subdural hematomas based solely on normal neurological examination is the most critical pitfall to avoid 1
• Failing to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1
• Delaying correction of secondary insults (hypotension, hypoxia) while monitoring 1
• Administering long-acting sedatives or paralytics before neurosurgical evaluation 1

Discharge Criteria

• Patient should remain neurologically intact throughout the observation period 1
• Repeat imaging at 6-8 hours should show no hemorrhage expansion 1, 2
• Patient must have adequate social support for home observation with clear discharge instructions regarding symptoms of delayed hemorrhage 2
• Close outpatient follow-up should be arranged 2