What is the most appropriate treatment—mannitol, hyperventilation, or craniotomy—for a patient who was initially conscious, then became unresponsive, was intubated prehospital, and whose post‑resuscitation CT shows an acute convex (extradural or acute subdural) hematoma?

Emergency Craniotomy for Acute Convex Hematoma with Neurological Deterioration

The most appropriate treatment is C) Craniotomy—this patient requires immediate surgical evacuation given the clinical deterioration from conscious to unresponsive with a convex hematoma (likely epidural or acute subdural) on CT. 1, 2, 3

Rationale for Immediate Surgical Intervention

Surgical evacuation is indicated for acute subdural hematoma with thickness >5 mm and midline shift >5 mm, and should be performed as soon as possible in patients with coma and significant mass effect. 1, 2 The clinical trajectory—initial consciousness followed by deterioration to unresponsiveness requiring intubation—represents a classic neurosurgical emergency that mandates craniotomy rather than temporizing medical measures 4, 3.

Key Clinical Indicators for Surgery

• A decline in Glasgow Coma Scale score of 2 or more points warrants emergency surgery. 1
• The appearance of anisocoria, bilateral mydriasis, or other signs of brain herniation constitutes an absolute indication for immediate surgical evacuation. 1
• Patients with acute subdural hematoma in coma (GCS <9) should undergo surgical evacuation as soon as possible, as delaying surgery is associated with poorer outcomes. 2, 3

Why Mannitol and Hyperventilation Are Insufficient

While osmotic therapy and ventilatory management have roles in acute intracranial hypertension, they serve only as temporizing measures for impending cerebral herniation while awaiting emergency neurosurgery—not as definitive treatment. 1

Limited Role of Medical Management

• Mannitol should be employed for impending cerebral herniation as a bridge to definitive surgical intervention, not as standalone therapy. 5, 1
• Hyperventilation (targeting PaCO₂ 35-40 mmHg) is recommended only as temporary treatment for acute herniation while preparing for craniotomy. 5, 1
• Routine hyperventilation in trauma patients without imminent herniation is associated with worse outcomes due to cerebral vasoconstriction and decreased cerebral blood flow. 5

Evidence Against Conservative Management

• Conservative management with close monitoring is appropriate only for stable patients without significant neurological deficits, particularly for small or asymptomatic hematomas. 1
• Conscious patients with small acute subdural hematomas (<10 mm thickness, midline shift <5 mm) without mass effect may be managed conservatively, but this patient has already deteriorated to unresponsiveness. 6, 7

Surgical Timing and Approach

Craniotomy with or without bone flap removal and duraplasty is the standard surgical approach for acute subdural hematoma with mass effect in comatose patients. 3

Critical Timing Considerations

• Surgical evacuation should be performed as soon as possible after the decision is made, as earlier intervention leads to better outcomes in patients with severe neurological deficits. 2, 4
• Emergency decompressive craniotomy in the emergency room (if the operating room is not immediately available) has been reported to improve outcomes in severe cases with GCS 3-4. 4
• The interval from injury to surgery influences outcome; delays beyond basic resuscitation worsen prognosis. 2, 4

Post-Operative Management Priorities

• Following craniotomy, intracranial pressure monitoring is recommended for patients with severe traumatic brain injury (GCS ≤8). 2
• Target cerebral perfusion pressure should be maintained between 60-70 mmHg; CPP >70 mmHg increases the risk of acute respiratory distress syndrome five-fold without neurological benefit. 1
• Intraparenchymal ICP probes are preferred over intraventricular drains due to lower infection rates (2.5% vs 10%) and lower hemorrhage risk (0-1% vs 2-4%). 1

Critical Pitfalls to Avoid

• Do not delay surgical intervention for "medical optimization" beyond basic resuscitation—this is a time-critical neurosurgical emergency. 2
• Do not rely on mannitol or hyperventilation as definitive treatment when surgical indications are present; these measures only buy time. 5, 1
• Do not administer long-acting sedatives or paralytics before establishing a neurological monitoring baseline, as this masks clinical deterioration. 8