Acute Subdural Hematoma - Surgical Decision (BTF Guidelines)

Algorithm Steps

1. ▶

   Start

   Acute Subdural Hematoma (aSDH) Identified

   CT showing crescent-shaped extra-axial hyperdense collection, crosses suture lines

   1. ◆

      Decision

      SDH Thickness >10mm?

      Measure maximum hematoma thickness on CT

      • Measure at widest point
      • Perpendicular to inner table of skull
      • Acute blood is hyperdense on CT
      1. ●

         Action

         SURGICAL EVACUATION

         SDH >10mm requires surgery regardless of GCS (BTF Level III)

         • Craniotomy preferred for acute SDH
         • Large bone flap for adequate exposure
         • Consider decompressive craniectomy if brain swelling
         1. ●

            Action

            Surgical Approach

            Craniotomy vs Craniectomy decision

            • Craniotomy: standard approach, bone flap replaced
            • Craniectomy: if brain swelling expected
            • Large bone flap for adequate exposure
            • Evacuate clot, control bleeding, inspect cortex
            1. ⚠

               Warning

               ⚠️ TIME-CRITICAL

               Early surgery (<4h) associated with better outcomes

               • GCS ≤8 with SDH: operate as soon as possible
               • Delay increases mortality
               • Do not wait for additional imaging if criteria met
      2. ◆

         Decision

         Midline Shift >5mm?

         Measure septum pellucidum displacement from midline

         • Measure at level of foramen of Monro
         • >5mm indicates significant mass effect
         • Risk of herniation increases with MLS
         1. ●

            Action

            SURGICAL EVACUATION

            Significant midline shift requires surgery (BTF Level III)

         2. ◆

            Decision

            Meeting Non-Operative Criteria?

            All must be met for conservative management

            • SDH ≤10mm thickness
            • Midline shift ≤5mm
            • Stable neurological exam
            • No pupillary abnormalities
            1. ●

               Action

               ICP Monitoring if GCS ≤8

               Place ICP monitor for comatose patients with small SDH

               • EVD preferred if hydrocephalus
               • Parenchymal monitor alternative
               • Target ICP <22 mmHg
               1. ◆

                  Decision

                  ICP >20 mmHg?

                  Persistent ICP elevation despite medical management

                  1. ●

                     Action

                     SURGICAL EVACUATION

                     Elevated ICP requires surgery (BTF Level III)

                  2. ◆

                     Decision

                     GCS Decline ≥2 Points?

                     Clinical deterioration from initial presentation

                     • Compare to baseline GCS
                     • Any decline warrants reassessment
                     • New pupillary changes critical
                     1. ●

                        Action

                        SURGICAL EVACUATION

                        Neurological decline requires surgery (BTF Level III)

                     2. ✓

                        Outcome

                        Continue Monitoring → Reassess

                        Stable patients continue conservative management with serial imaging

            2. ●

               Action

               Conservative Management

               Non-operative care for small, stable SDH

               • ICU admission
               • Neurological checks q1h
               • Repeat CT at 6-8 hours
               • Reverse anticoagulation if applicable
               • Seizure prophylaxis per guidelines