Patientem Fortuna Adiuvat: The Delayed Treatment of Surgical Acute Subdural Hematomas—A Case Series

Background: Current guidelines prescribe emergent decompression of acute subdural hematomas (aSDHs) with width 10 mm or larger or midline shift 5 mm or larger. A subset of patients who meet these criteria, including those with high Glasgow Coma Scale (GCS) scores and coagulopathy because of medication or multiple medical comorbidities, may be treated conservatively until the hematoma can be removed by burr hole drainage. We present a series of conservatively managed surgical patients with aSDH, examining their hospital course and outcomes. Methods: Patients were included who met guidelines for surgery on admission but who had decompression delayed until it could be accomplished by burr hole drainage. Charts were reviewed for presentation, computed tomography scan findings, and outcomes. Patients were classified according to outcome and whether their eventual surgery was scheduled or emergent. Results: Eighteen patients were included with a mean age of 70.2 years. Average GCS score at presentation was 14.6 ± 0.6. Most patients were using some form of blood-thinning medication at presentation (72.2%). Admission CT scan revealed aSDH with a mean width of 13.6 mm and midline shift of 6.6 mm. Average total length of stay was 28.4 ± 17.0 days, of which 14.2 ± 9.2 days were spent in the intensive care unit. Outcomes were generally acceptable, with an average Glasgow Outcome Scale score at discharge of 3.8 ± 1.4. There were only 2 deaths, neither of which was related to the initial trauma or a neurologic process. Conclusions: Delayed treatment of aSDH by burr hole drainage is an effective option in certain patients who are suboptimal craniotomy candidates. Acceptable outcomes may be achievable with this conservative approach, when applied in appropriate patients.