What is the next best step for an elderly patient with a subdural hematoma, significant midline shift of 13mm, and a Glasgow Coma Scale (GCS) score of 7/15, who has been intubated and resuscitated?

Urgent Craniotomy is the Next Best Step

This patient requires immediate surgical evacuation via craniotomy given the combination of severe neurological impairment (GCS 7/15), significant mass effect (13mm midline shift), and signs of lateralization indicating impending or active herniation. 1, 2

Rationale for Immediate Surgical Intervention

The clinical presentation meets all criteria for emergency neurosurgery:

• GCS 7/15 represents severe traumatic brain injury requiring urgent decompression, as patients with subdural hematoma, midline shift >5mm, and coma require surgical evacuation as soon as possible to reduce mortality and improve neurological outcomes 1, 3

• 13mm midline shift far exceeds the surgical threshold of 5mm, and when combined with signs of lateralization (indicating uncal herniation), this represents a time-critical neurosurgical emergency 1, 2

• The American Heart Association/American Stroke Association strongly recommends decompressive craniectomy with or without hematoma evacuation to reduce mortality in patients with large hematomas, significant midline shift, and coma 1, 2

Why Other Options Are Inappropriate as Primary Management

Mannitol (Option A) and head elevation (Option B) are temporizing measures only:

• Osmotherapy with mannitol is recommended only while awaiting or during emergency neurosurgery in cases of cerebral herniation, not as definitive treatment 4
• These adjuncts do not address the underlying mass effect requiring surgical decompression 4

Hyperventilation (Option C) should be avoided except as a brief temporizing measure:

• Target PaCO2 should be 35-40 mmHg during interventions for emergency neurosurgery 4
• Brief periods of PaCO2 4.0-4.5 kPa (30-34 mmHg) may be used only temporarily if impending uncal herniation while preparing for surgery 4
• Prolonged hyperventilation causes cerebral vasoconstriction and worsens outcomes 4

Critical Timing Considerations

Delaying surgical intervention beyond basic resuscitation is contraindicated:

• Surgical evacuation should be performed as soon as possible after the decision is made, as delays in patients with significant midline shift and low GCS scores are associated with poorer outcomes 1
• Earlier intervention leads to better outcomes, particularly in patients with severe neurological deficits 1, 2
• Do not delay transfer for "medical optimization" beyond basic resuscitation in this time-critical emergency 1

Peri-Operative Management Priorities

While preparing for immediate craniotomy, maintain:

• Systolic blood pressure >110 mmHg (and MAP >90 mmHg) to ensure adequate cerebral perfusion 4
• PaCO2 4.5-5.0 kPa (35-40 mmHg) with brief reduction to 4.0-4.5 kPa only if impending herniation 4
• PaO2 ≥13 kPa to prevent hypoxic secondary injury 4
• Osmotherapy (mannitol or hypertonic saline) may be administered while mobilizing for surgery if signs of herniation worsen 4, 3

Important Caveats

Elderly patients with subdural hematoma have high mortality, but age alone is not a contraindication to surgery when there is potential for meaningful recovery 3:

• A low GCS score (3-8), bilateral pupil abnormalities, and midline shift >10mm with SDH thickness < midline shift are unfavorable prognostic factors 3
• However, with GCS 7/15 and signs of lateralization (not bilateral fixed pupils), surgery remains indicated 3

Coagulopathy reversal should occur simultaneously with surgical preparation, not delay it:

• Reverse anticoagulation immediately if present 1
• Maintain platelet count >50,000/mm³ for neurosurgery (higher values advisable) 4
• Maintain PT/aPTT <1.5 times normal control 4