A 35-year-old man is brought to the emergency department after a high-velocity road traffic accident. He is comatose with a fixed dilated left pupil. CT head shows an acute subdural hematoma with a thickness of 15 mm and midline shift of 8 mm. What is the definitive management?

• A Conservative management with mannitol and close observation
• B Burr hole drainage
• C Decompressive craniectomy as a staged procedure
• D Emergency craniotomy for evacuation ✓

Explanation

Acute subdural hematoma with thickness greater than 10 mm or midline shift greater than 5 mm on CT requires emergency craniotomy for evacuation, regardless of Glasgow Coma Scale. This patient meets both criteria and has a fixed dilating pupil indicating uncal herniation. Burr holes are inadequate for acute clotted subdural hematomas. Conservative management is reserved for small, asymptomatic collections.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.