Acute Subdural Hematoma · Surgical Evacuation vs Observation

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Thickness/midline + GCS dynamics + pupils/ICP
   Thickness and midline shift? GCS dynamic change? Pupils and ICP?
   • Thickness >10 mm or midline shift >5 mm (any GCS) → Thickness >10 mm or midline >5 mm → evacuate
   • GCS <9 coma, thin hematoma (<10 mm/<5 mm), but GCS dropped ≥2 from injury, or fixed dilated pupil, or ICP >20 → Coma + deterioration signs → emergency evacuation
   • Thin, stable, no focal deficit, normal pupils, controllable ICP → Thin and stable → close observation
2. [End] Thickness >10 mm or midline >5 mm → evacuate
   Thickness >10 mm or midline shift >5 mm → evacuate regardless of GCS; large craniotomy evacuation, with decompressive craniectomy for marked/malignant brain swelling (RESCUE-ASDH showed craniectomy reduces reoperation but increases disability). Comatose patients get ICP monitoring.
3. [End] Coma + deterioration signs → emergency evacuation
   Coma (GCS <9) even with a thin hematoma: if GCS dropped ≥2 from injury to admission, or asymmetric/fixed dilated pupils, or ICP >20 mmHg → emergency evacuation. All comatose acute subdural hematomas should have ICP monitoring.
4. [End] Thin and stable → close observation
   Thin, stable, no focal deficit, normal pupils, controllable ICP → close observation + serial CT + neuromonitoring; in the elderly with low-energy injury, may wait for it to become chronic then do a less invasive burr-hole/small-flap drainage. Operate once it deteriorates.

Source guidelines & references

• Surgical management of acute subdural hematoma (Brain Trauma Foundation surgical TBI guideline; Bullock 2006; RESCUE-ASDH 2023)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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