In an adult or elderly patient with recent head trauma presenting with left‑sided headache, focal weakness, sensory loss, aphasia, or altered consciousness, what is the most likely diagnosis and what is the recommended evaluation and management?

Left-Sided Subdural Hematoma: Diagnosis and Management

In an adult or elderly patient with recent head trauma presenting with left-sided headache, focal weakness, sensory loss, aphasia, or altered consciousness, the most likely diagnosis is a left-sided subdural hematoma, and immediate non-contrast head CT imaging is mandatory, followed by urgent neurosurgical consultation if imaging confirms the diagnosis. 1, 2

Most Likely Diagnosis

The constellation of left-sided symptoms (headache, focal weakness, sensory loss, aphasia) following head trauma strongly indicates a left-sided subdural hematoma with mass effect causing ipsilateral compression and potentially contralateral motor deficits. 3, 4 Subdural hematomas in older adults frequently present with these focal neurologic signs, and aphasia specifically localizes the lesion to the dominant (typically left) hemisphere. 4, 5

Immediate Evaluation Required

Neuroimaging

• Non-contrast head CT scan must be obtained immediately in any patient with head trauma presenting with focal neurologic deficits, altered consciousness, or age >64 years with vomiting or suspected seizure activity. 6, 2
• CT imaging is the gold standard for diagnosing subdural hematoma and determining thickness, midline shift, and associated injuries. 1, 3
• The American College of Emergency Physicians Level A recommendation states that head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia if any of the following are present: headache, vomiting, age >60 years, focal neurologic deficit, or coagulopathy. 6

Urgent Neurological Assessment

• Document Glasgow Coma Scale (GCS) score with individual components (Eye, Motor, Verbal) and pupillary size/reactivity immediately. 1
• Perform focused neurological examination specifically assessing for: pupillary asymmetry, motor weakness (face, arm, leg), sensory deficits, speech abnormalities (aphasia, dysarthria), and signs of herniation (posturing, pupillary changes). 1, 2
• Monitor GCS every 15 minutes for the first 2 hours, then hourly for 12 hours, as a decline of ≥2 points warrants immediate repeat CT scanning. 1

Laboratory Studies

• Obtain complete blood count, comprehensive metabolic panel, coagulation studies (PT/INR, aPTT), and platelet count immediately. 1, 2
• These are critical for identifying coagulopathy requiring reversal and guiding transfusion thresholds. 1

Critical Management Steps

Immediate Stabilization

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg throughout the acute phase to ensure adequate cerebral perfusion. 1
• Target cerebral perfusion pressure (CPP) between 60-70 mmHg after ICP monitor placement if patient is comatose (GCS ≤8). 1
• Maintain PaO2 between 60-100 mmHg and PaCO2 between 35-40 mmHg (normocapnia). 1
• Reserve hypocapnia (temporary hyperventilation) only for cases of cerebral herniation while awaiting emergency neurosurgery. 1

Anticoagulation Reversal

• Immediately hold and reverse any anticoagulation (warfarin, NOACs) or antiplatelet agents (aspirin, clopidogrel) upon diagnosis of subdural hematoma. 1
• Elderly patients (≥65 years) on aspirin have a 3-fold increased risk of hemorrhage progression (26% vs 9% in non-anticoagulated patients). 1
• Maintain platelet count >50,000/mm³ and PT/aPTT <1.5 times normal control. 1

Neurosurgical Consultation Criteria

Urgent neurosurgical consultation is required if any of the following are present: 1

• Subdural hematoma thickness >5 mm with midline shift >5 mm
• GCS decline of ≥2 points from initial assessment
• Development of pupillary changes or posturing indicating herniation
• Development or worsening of focal neurological deficits indicating mass effect
• Midline shift >5 mm with low GCS scores

Surgical evacuation should be performed as soon as possible after the decision is made, as delaying surgery in patients with significant midline shift and low GCS scores is associated with poorer outcomes. 1

Admission and Monitoring Requirements

• Any documented subdural hematoma on CT requires admission, regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients. 1
• Admit for close neurological observation for 24-72 hours with serial clinical assessments. 1
• 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. 1
• All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension require ICP monitoring regardless of whether they undergo emergency neurosurgery. 1

Special Considerations for Elderly Patients

Subdural hematomas in older adults present unique diagnostic challenges because symptoms—headache, confusion, ataxia, hemiparesis—can mimic dementia, stroke, transient ischemic attacks, or normal pressure hydrocephalus. 4 The Canadian CT Head Rule high-risk criteria (age >64 years, vomiting, suspected seizure activity) mandate immediate head CT imaging in elderly patients. 2

Critical Pitfalls to Avoid

• Do not discharge patients with documented subdural hematomas based solely on normal neurological examination, as delayed deterioration requiring neurosurgery can occur. 1, 4
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration. 1
• Do not fail to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 1
• Do not delay transfer for "medical optimization" beyond basic resuscitation in patients requiring neurosurgical intervention, as this is a time-critical emergency. 1
• Do not use corticosteroids (such as dexamethasone) for traumatic brain injury management, as they may worsen outcomes. 1

Prognosis

Patients with subdural hematomas and focal neurologic signs should be considered for surgical intervention, whereas asymptomatic patients or patients with only headache complaints can be managed medically or followed with serial neuroimaging. 4 Early diagnosis and intervention result in improved prognosis, with good outcomes dependent on prompt evaluation and immediate treatment when necessary. 3, 7