What is the next step in managing an elderly patient with a subdural hematoma, significant midline shift, and low Glasgow Coma Scale (GCS) score of 7/15 after intubation and resuscitation?

Urgent Craniotomy (Option D)

This patient requires immediate surgical evacuation via craniotomy—this is the definitive next step after intubation and resuscitation. 1, 2, 3

Why Urgent Surgery is Mandatory

Your patient meets absolute criteria for emergency surgical intervention:

• Midline shift of 13 mm (far exceeds the 5 mm threshold) 1, 4, 2, 3
• GCS of 7/15 (severe traumatic brain injury with coma) 1, 2, 3
• Acute subdural hematoma with signs of lateralization (indicating mass effect and herniation risk) 1, 2, 3

The French Society of Anaesthesia guidelines explicitly state that acute subdural hematoma with thickness >5 mm and midline shift >5 mm requires removal, and your patient has more than double this threshold. 1

Evidence Supporting Immediate Craniotomy

Decompressive craniectomy with or without hematoma evacuation is specifically recommended by the American Heart Association/American Stroke Association for patients who are:

• In coma 1, 2
• Have large hematomas with significant midline shift 1, 4, 2
• Have elevated intracranial pressure refractory to medical management 1, 2

The 2006 Neurosurgery guidelines are unequivocal: "An acute SDH with thickness >10 mm or midline shift >5 mm should be surgically evacuated, regardless of GCS score" and "surgical evacuation should be performed as soon as possible." 3

Why the Other Options Are Wrong

A. IV Mannitol - Temporizing Only

• Mannitol is indicated for reduction of intracranial pressure but is not a substitute for surgery when surgical criteria are met 5
• The FDA label specifies mannitol for ICP reduction, but your patient needs definitive decompression, not temporizing measures 5
• Mannitol may be used during surgical preparation but should not delay craniotomy 5

B. Elevate Head of Bed - Supportive Care Only

• Head elevation is a basic supportive measure that does not address the life-threatening mass effect 1
• This intervention is appropriate for conservative management when midline shift is <5 mm and GCS is preserved 6, 7
• Your patient is far beyond conservative management criteria 2, 6

C. Hyperventilation - Dangerous Without Surgery

• Hyperventilation causes cerebral vasoconstriction and risks brain ischemia 1
• The French guidelines warn that hypocapnia is a risk factor for brain ischemia 1
• Target PaCO2 should be 35-40 mmHg, not aggressive hyperventilation 6
• This may be used as a bridge to surgery in extremis but is not the definitive management 1

Timing is Critical

Surgery should be performed as soon as possible after the decision is made:

• Meta-analysis suggests surgical intervention within 8 hours of hemorrhage may improve outcomes 4
• Delayed surgery in patients with severe neurological deficits is associated with substantially worse outcomes 2, 6
• The 2018 French guidelines emphasize that removal should occur "as soon as possible" 1

Important Caveat About Delayed Surgery

While one 2020 study suggested delayed surgery might be safe in elderly patients with good neurologic exams who can be closely monitored 8, your patient has:

• GCS 7/15 (not a "good neurologic exam") 8
• 13 mm midline shift (massive, not borderline) 8
• Signs of lateralization (active herniation) 8

This patient does not meet criteria for conservative or delayed management. 2, 8, 7

Post-Operative Management

After craniotomy, this patient will require:

• Intracranial pressure monitoring (mandatory for GCS ≤8) 1, 2, 3
• Cerebral perfusion pressure maintained at 60-70 mmHg 2, 6
• Avoidance of hypotension (maintain SBP >100 mmHg or MAP >80 mmHg) 6