What is the appropriate management for a 65-year-old male patient with a subacute subdural hematoma, stable vital signs, and a Glasgow Coma Scale (GCS) score of 15, presenting with numbness of the upper limb and mouth deviation two weeks after head trauma?

From the Guidelines

The correct management for this 65-year-old male with a subacute subdural hematoma, stable vitals, and GCS of 15 is craniotomy (option B).

Reasons for Craniotomy

• Craniotomy is preferred for subacute subdural hematomas because the blood has begun to clot and organize, making it difficult to evacuate through a simple burr hole 1.
• The patient's neurological symptoms (upper limb numbness and mouth deviation) indicate mass effect from the hematoma, requiring surgical intervention despite his stable GCS.

Comparison with Burr Hole

• Burr holes are typically used for acute subdural hematomas where the blood is still liquid and can drain easily through small openings.
• Craniotomy provides better visualization and more complete evacuation of the organized blood collection.

Rationale Against Conservative Management

• Conservative management would be inappropriate given these pressure symptoms, and simple admission without definitive treatment would not address the underlying problem.
• The risk of delayed ICH after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare, and most studies support the notion that patients on anticoagulants, or antiplatelet agents, with a normal initial head CT after blunt trauma and who are neurologically intact can be safely discharged 1.

Procedure Details

• The craniotomy procedure involves removing a section of skull, evacuating the hematoma, and then replacing the bone flap, allowing for thorough treatment of the subacute collection.
• This approach is supported by the most recent and highest quality study, which emphasizes the importance of prompt and effective treatment for subacute subdural hematomas 1.

From the Research

Management of Subacute Subdural Hematoma

The patient in question is a 65-year-old male with a subacute subdural hematoma, presenting with numbness of the upper limb and mouth deviation, but with stable vitals and a GCS score of 15. The management of such a case can be considered based on the following points:

• Burr Hole vs Craniotomy:
  • Burr hole surgery is often considered for emergency situations, especially in cases of acute subdural hematoma where immediate relief of pressure is necessary 2, 3.
  • Craniotomy is a more extensive procedure that may be performed after initial stabilization or in cases where burr hole surgery is not sufficient 2, 4.
• Indications for Each Procedure:
  • Burr hole surgery is indicated in emergency situations, especially for patients with severe acute subdural hematoma and signs of increased intracranial pressure 2, 5.
  • Craniotomy may be preferred for cases where a more thorough evacuation of the hematoma is necessary, or in cases of chronic subdural hematoma where the risk of recurrence is higher 4.
• Considerations for the Patient:
  • The patient's age, comorbidities, and overall clinical condition should be taken into account when deciding between burr hole surgery and craniotomy 5, 4.
  • The patient's GCS score of 15 indicates a good level of consciousness, which may influence the decision towards a less invasive approach initially.
• Monitoring and Management:
  • Intracranial pressure (ICP) monitoring may be beneficial in managing patients with severe brain injuries, including those with subdural hematomas, as it can guide the need for surgical intervention and predict outcomes 6.

Decision for the Given Scenario

Given the patient's stable condition and the presence of a subacute subdural hematoma, the initial approach could be conservative management with close monitoring of the patient's condition and repeated imaging as necessary. However, the decision between burr hole surgery and craniotomy, if surgical intervention becomes necessary, would depend on the patient's clinical progression and the specific characteristics of the hematoma.

• Options:
  • Admission and workup (A) could be considered for close monitoring and further evaluation.
  • Burr hole surgery (C) might be indicated if the patient's condition deteriorates or if there's evidence of increased intracranial pressure.
  • Craniotomy (B) could be an option if a more extensive evacuation of the hematoma is required.
  • Conservative management at home (D) might not be appropriate given the need for close monitoring and potential for rapid deterioration.