In general, initial surgical indication may be based on the patients GCS score, pupillary examination, and CT findings. Neurological deterioration and/or increase in ICP may also be an important factor in delayed decision 1).
Although the presurgical management of patients with acute traumatic subdural hematoma prioritizes rapid transport to the operating room, there is conflicting evidence regarding the importance of time interval from injury to surgery with regards to outcomes.
Significantly better outcome of clinical recovery with less cases of morbidity and deaths had occurred in patients in which TSDH was removed with the Decompressive craniectomy (DC) technique within 24 hours after the time of injury and also if a DC surface had had size over 40 ccm, in comparison to the group of patients that had TSDH removed with DC technique within longer period of time than 24 hours after the time of injury and also better than the control group 2).
In surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, or left “riding” to provide partial skull decompression, or removed.
A study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome, and recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH 3).
Acute subdural hematoma evacuations frequently necessitate large craniotomies with extended operative times and high relative blood loss, which can lead to additional morbidity for the patient.