From the Guidelines
The treatment for a subdural hematoma in a patient with two months of head trauma history who presents with vomiting, tiredness, and altered consciousness is burr hole drainage (option B). This approach is supported by the most recent and highest quality study, which recommends burr hole drainage for symptomatic subdural hematomas with significant mass effect 1. The patient's symptomatic presentation with neurological deterioration, including vomiting, tiredness, and altered consciousness, indicates the need for prompt surgical intervention to prevent further deterioration and improve outcome.
The evidence from the study published in the Journal of Neurology, Neurosurgery and Psychiatry in 2023 1 suggests that burr hole drainage is the preferred initial treatment for chronic subdural hematomas, as it allows for effective drainage of the liquefied blood collection with minimal invasiveness. In contrast, serial CT scans (option A) would be insufficient given the patient's symptomatic decline, while craniotomy (option C) is usually reserved for acute subdural hematomas or chronic cases with multiple loculations or solid components that cannot be adequately drained through burr holes.
Key points to consider in the management of this patient include:
- The presence of symptoms such as vomiting, tiredness, and altered consciousness, which indicate significant mass effect and the need for prompt surgical intervention
- The chronic nature of the subdural hematoma, which suggests that the blood has likely liquefied and can be effectively drained through burr holes
- The importance of prompt treatment to prevent further neurological deterioration and improve the patient's outcome, as supported by the study published in the Journal of Neurology, Neurosurgery and Psychiatry in 2023 1.
From the Research
Treatment Options for Subdural Hematoma
The treatment for subdural hematoma depends on various factors, including the size and location of the hematoma, the patient's age and overall health, and the presence of any underlying medical conditions.
- Burr hole evacuation is a surgical procedure that involves making a small hole in the skull to drain the hematoma, as studied in 2, 3, 4, 5.
- Craniotomy is a more invasive surgical procedure that involves removing a portion of the skull to access the hematoma, as mentioned in 2, 3, 4.
- Serial CT scans may be used to monitor the size and location of the hematoma, as well as to check for any signs of increased intracranial pressure, but this is not a treatment option.
Considerations for Treatment
The choice of treatment depends on the specific characteristics of the patient and the hematoma.
- For example, a study published in 2 found that delayed burr hole evacuation was associated with a lower risk of complications compared to immediate craniotomy in older patients with low-energy trauma.
- Another study published in 3 found that burr hole trepanation was associated with a lower rate of recurrence compared to craniotomy in patients with chronic subdural hematoma.
- A study published in 4 compared the outcomes of burr hole drainage and small craniotomy with closed-system drainage for chronic subdural hematomas, and found that burr hole drainage was associated with a lower recurrence rate.
- Endoscopic burr hole evacuation is a minimally invasive technique that has been used to evacuate acute subdural hematomas, as reported in 5.
Patient-Specific Factors
Patient-specific factors, such as age and overall health, can also influence the choice of treatment.
- For example, older patients may be at higher risk for complications from invasive surgical procedures, and may therefore be more suitable for less invasive treatments such as burr hole evacuation, as studied in 2.