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Acute Subdural Haematoma - Surgical Decision (BTF 2006)

Acute Subdural Haematoma - Surgical Decision (BTF 2006): Acute subdural haematoma on CT (adult) → Check first: child, chronic SDH, goals of care → On an...

Pathway Overview

18 steps

Algorithm Steps

18 total

  1. 01Start

    Acute subdural haematoma on CT (adult)

    Acute (hyperdense) crescent-shaped collection after trauma. Call neurosurgery now; no neurosurgery on site: call the retrieval service now for transfer. Resuscitate: avoid SpO2 <90% and SBP <110 mmHg (<100 mmHg if aged 50-69).

  2. 02Warning

    Check first: child, chronic SDH, goals of care

    These patients need a different plan. Do not delay care of the others.

    • Child: this adult pathway does not apply; get paediatric neurosurgery advice. Infant SDH: consider abusive head trauma.
    • Chronic or mixed-density SDH: different criteria; this pathway does not apply.
    • Frail, very old or advance care directive: agree goals of care with patient, family and neurosurgeon before surgery.
  3. 03Warning

    On an anticoagulant or antiplatelet drug? Reverse now, before and during surgery

    Operating without reversal risks uncontrolled bleeding. Treat on history; do not wait for test results.

    • Reversal must not delay indicated surgery: run both in parallel.
    • No routine platelet transfusion for antiplatelet drugs; it caused harm in ICH without surgery.
    • Doses and agents: next step.
  4. 04Action

    All patients: stop antithrombotics; reverse by agent

    Adult doses. Check for antithrombotic use in every patient. Known heparin-induced thrombocytopenia (HIT): do not give Beriplex (contains heparin); get haematology advice.

    • Warfarin, INR 1.5 or more (adult): vitamin K 5-10 mg IV plus 4F-PCC (Beriplex) 50 IU/kg IV (weight up to 100 kg; max 5000 IU). Consider a lower PCC dose if INR 1.5-1.9.
    • Dabigatran (adult): idarucizumab 5 g IV (2 x 2.5 g/50 mL vials). No idarucizumab: PCC per haematology.
    • Apixaban or rivaroxaban: andexanet is not TGA-registered. Give PCC (off-label) per local haematology protocol.
    • Antiplatelet drug: no routine platelet transfusion (harm when no surgery). Consider platelets for aspirin before craniotomy.
    • Unfractionated heparin: protamine IV, dose by heparin given, no faster than 50 mg per 10 min. LMWH: protamine reverses only partly. Get haematology advice.
    • Tests: INR, APTT, platelets, fibrinogen, group and hold; time of last DOAC dose.
  5. 05Warning

    TIME-CRITICAL: operate as soon as possible when criteria are met

    Surgical evacuation should be done as soon as possible (BTF 2006).

    • Do not wait for reversal to finish or for more imaging once criteria are met.
    • Reversal, resuscitation and theatre preparation run in parallel.
    • Any deterioration: urgent repeat CT and re-apply the criteria.
  6. 06Action

    Signs of herniation while waiting for theatre or transfer: temporise

    Only a bridge to surgery. Do not delay theatre or transfer. Agree measures with neurosurgeon or ICU.

    • Signs: new pupil asymmetry or fixed dilated pupil, falling GCS, hypertension with bradycardia.
    • Mannitol 0.25-1 g/kg IV (adult; max 1 g/kg per dose), or hypertonic saline per local protocol. Avoid SBP <90 mmHg.
    • Brief hyperventilation only as a temporising measure; do not take PaCO2 to 25 mmHg or less.
  7. 07Decision

    Thickness >10 mm or midline shift >5 mm on CT?

    Thickness: maximum, perpendicular to the inner table. Midline shift: septum pellucidum at the foramen of Monro.

  8. If Yes
    1. 08Action

      Thickness >10 mm or shift >5 mm: evacuate as soon as possible, at any GCS

      Surgical evacuation is indicated regardless of GCS (BTF 2006).

    2. 09Action

      Surgery: craniotomy, bone flap replaced or left out

      In coma (GCS below 9): craniotomy with or without bone flap removal and duraplasty (BTF 2006).

      • Large bone flap (median 13 cm in RESCUE-ASDH).
      • Flap out (craniectomy) vs replaced: similar 12-month outcomes (RESCUE-ASDH 2023).
      • Flap replaced: more reoperation within 2 weeks (14.6% vs 6.9%). Flap out: more wound complications (12.2% vs 3.9%).
      • After surgery, GCS below 9: ICP monitoring and ICU care.
    3. 10Outcome

      Reassess: any deterioration needs urgent CT and a new surgical decision

      Re-apply the criteria at each deterioration. Neurosurgeon decides on restarting antithrombotics.

    If No
    1. 11Decision

      Small SDH (10 mm or less, shift 5 mm or less): GCS below 9 (coma)?

      Use the GCS after resuscitation.

    2. If Yes
      1. 12Decision

        Coma with small SDH: abnormal pupils or GCS fall of 2 or more?

        Asymmetric pupils, or fixed and dilated pupils, or GCS fell by 2 or more points between injury and hospital admission.

      2. If Yes
        1. 13Action

          Coma plus abnormal pupils or GCS fall of 2 or more: evacuate as soon as possible

          Surgical evacuation is indicated (BTF 2006).

        2. Path rejoins step 09Shared downstream outcome
        If No
        1. 14Action

          Coma, no pupil or GCS-fall criterion: insert ICP monitor

          All comatose (GCS below 9) patients with acute SDH need ICP monitoring (BTF 2006). ICU care.

          • Monitor type (parenchymal or EVD) per neurosurgeon.
          • Tiered ICP treatment per local severe TBI protocol (BTF 2016 threshold: ICP >22 mmHg).
          • Consider 7 days of seizure prophylaxis for early seizures (BTF 2016, severe TBI).
        2. 15Decision

          Coma with small SDH: ICP above 20 mmHg?

          ICP >20 mmHg is the surgical criterion for this group (BTF 2006).

        3. If Yes
          1. 16Action

            Coma plus ICP above 20 mmHg: evacuate as soon as possible

            Surgical evacuation is indicated (BTF 2006).

          2. Path rejoins step 09Shared downstream outcome
          If No
          1. 17Action

            Coma, ICP 20 mmHg or less: non-operative ICU care

            Continue ICP-guided ICU care. Re-apply the surgical criteria if ICP rises or pupils change.

            • Keep antithrombotics stopped.
            • Repeat CT if ICP rises, pupils change or the patient deteriorates.
          2. Path rejoins step 10Shared downstream outcome
      If No
      1. 18Action

        GCS 9-15 with small SDH: non-operative care with close review

        Neurosurgeon decides. Abnormal pupils or a new focal deficit at any time: urgent neurosurgical review and CT.

        • Admit to a monitored bed under neurosurgery or trauma.
        • Observe GCS, pupils and limbs half-hourly until GCS 15, then per NICE schedule.
        • Urgent review and consider immediate CT if GCS falls (1 point for 30 min, 3 eye or verbal points, or 2 motor points), pupils become unequal, new limb weakness, severe headache or persistent vomiting.
        • Planned repeat CT per neurosurgeon.
        • Keep antithrombotics stopped; restart only on neurosurgical advice.
      2. Path rejoins step 10Shared downstream outcome

Guideline Source

Bullock MR et al. Surgical Management of Acute Subdural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S16-S24

DOI: 10.1227/01.NEU.0000210364.29290.C9View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults with acute traumatic SDH only. Not for children or chronic or mixed-density SDH.
  • Surgical criteria are from 2006 guidelines based on low-level (class III) evidence; the neurosurgeon makes the final decision.
  • Antithrombotic reversal doses are for adults; follow local haematology protocol for DOACs other than dabigatran.
  • ICP monitoring and emergency neurosurgery need a neurosurgical centre; rural and remote sites need early retrieval.

Contraindicated Populations

Children (paediatric TBI guidelines apply)Chronic or subacute subdural haematomaNon-traumatic subdural haematoma

Applicable Regions

AUNZUSEUGlobal

AU: 4F-PCC (Beriplex) replaced Prothrombinex-VF for warfarin reversal (MJA 2025). Andexanet alfa is not on the ARTG. Rural and remote sites: early discussion and retrieval to a neurosurgical centre.

Global: BTF Surgical Management of TBI guidelines (Bullock 2006) are still the current surgical-indication guidance for acute SDH; RESCUE-ASDH (NEJM 2023) informs flap choice.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Acute Subdural Haematoma - Surgical Decision (BTF 2006)?

The Acute Subdural Haematoma - Surgical Decision (BTF 2006) is a management clinical algorithm for Neurosurgery. It provides a structured decision tree to guide clinical decision-making, based on Bullock MR et al. Surgical Management of Acute Subdural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S16-S24.

What guideline is the Acute Subdural Haematoma - Surgical Decision (BTF 2006) based on?

This algorithm is based on Bullock MR et al. Surgical Management of Acute Subdural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S16-S24 (DOI: 10.1227/01.NEU.0000210364.29290.C9).

What are the limitations of the Acute Subdural Haematoma - Surgical Decision (BTF 2006)?

Known limitations include: Adults with acute traumatic SDH only. Not for children or chronic or mixed-density SDH.; Surgical criteria are from 2006 guidelines based on low-level (class III) evidence; the neurosurgeon makes the final decision.; Antithrombotic reversal doses are for adults; follow local haematology protocol for DOACs other than dabigatran.; ICP monitoring and emergency neurosurgery need a neurosurgical centre; rural and remote sites need early retrieval.. Individual patient factors may require deviation from these recommendations.

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