Acute Subdural Hematoma in Coma (GCS <9) When Nonoperative Management Has Failed

This protocol addresses the comatose patient — Glasgow Coma Scale score below 9 — with a thin acute subdural hematoma and minimal midline shift, in whom initial nonoperative management with intracranial pressure monitoring has not maintained neurological stability.

Clinical Scenario

Coma with Glasgow Coma Scale score less than 9
Acute subdural hematoma less than 10 mm thick
Midline shift less than 5 mm on CT scan

When the Prior Approach Is No Longer Sufficient

Previous management: Nonoperative management with intracranial pressure (ICP) monitoring in the neurosurgical intensive care unit.

Escalation is indicated when any of the following criteria are present:

GCS score has decreased by 2 or more points since the time of injury
Asymmetric or fixed and dilated pupils
Intracranial pressure exceeds 20 mm Hg

Next Step

Once escalation criteria are met, the structured protocol specifies a defined surgical approach to lesion evacuation — the operative technique and timing considerations are detailed in the full regimen.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1227/01.NEU.0000210364.29290.C9

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.

If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.

View source ↗