This protocol defines the management approach for comatose patients with acute subdural hematoma (SDH) presenting with a Glasgow Coma Scale (GCS) score below 9, a hematoma less than 10 mm thick, and a midline shift less than 5 mm on CT scan — a specific subset where imaging findings may permit a non-surgical pathway under strict monitoring.
In comatose patients with acute SDH who meet these specific imaging thresholds, the protocol involves nonoperative management with intracranial pressure (ICP) monitoring in the neurosurgical intensive care unit — contingent on a defined set of neurological and clinical conditions being present and maintained. The full eligibility criteria, monitoring requirements, and escalation decision points are detailed in the structured protocol.
DOI: 10.1227/01.NEU.0000210364.29290.C9
All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring.
Patients who present in a coma (GCS < 9) but with an SDH with a thickness less than 10 mm and an MLS less than 5 mm can be treated nonoperatively, providing that they undergo ICP monitoring, they are neurologically stable since the injury, they have no pupillary abnormalities, and they have no intracranial hypertension (ICP > 20 mm Hg).
A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg.
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