Acute Small Subdural or Epidural Hematoma Management in the Elderly

Initial Evaluation

The American College of Radiology recommends a non-contrast computed tomography (CT) scan of the head as the initial evaluation for acute small subdural or epidural hematoma, allowing characterization of the size, location, and mass effect of the hematoma 1, 3
A complete neurological assessment with the Glasgow Coma Scale (GCS), pupillary examination, and evaluation of focal neurological deficits is essential 2, 4
The use of anticoagulants or antiplatelet agents should be verified, as they can increase the risk of hematoma expansion 5

The absence of signs of intracranial hypertension or neurological deterioration is a key criterion for conservative management 2, 4

Close neurological observation with serial assessments of the GCS, pupils, and focal deficits is crucial 2, 4
Consideration of repeat CT scan of the head at 24 hours, especially in patients on anticoagulants, is recommended 5

An increase in hematoma size on follow-up CT scan is an indication for surgical intervention 2, 4
Development of signs of intracranial hypertension or significant mass effect is also an indication for surgical intervention 2

Maintaining euvolemia and avoiding hypovolemia to optimize cerebral perfusion is important in the post-treatment monitoring of elderly patients 4
Monitoring for complications such as seizures, infection, and hematoma expansion is essential 4
Early rehabilitation should be considered to prevent complications related to immobility 4

Small hematomas in elderly patients should not be underestimated, as they can expand rapidly, especially in those on anticoagulants 5, 6
Recognizing that epidural hematomas are limited by cranial sutures, while subdural hematomas can cross these sutures, aids in differential diagnosis 6