A 6‑year‑old child with a crescent‑shaped acute subdural hematoma, progressive drowsiness, nausea, vomiting, and a Glasgow Coma Scale above eight—what is the best immediate management?

Management of Pediatric Acute Subdural Hematoma with Declining Neurological Status

This child requires immediate hematoma evacuation (Option B) because the combination of a crescent-shaped subdural hematoma with progressive neurological deterioration (drowsiness, vomiting, decreased GCS) indicates mass effect and impending herniation, which mandates urgent neurosurgical intervention regardless of the absolute GCS value. 1, 2, 3

Why Surgical Evacuation is Indicated

The presence of progressive neurological decline with a subdural hematoma is an absolute indication for urgent neurosurgical evaluation and likely evacuation, even when GCS remains above 8. 2, 3 The key surgical criteria are:

• Any acute subdural hematoma with focal neurological deficits requires immediate neurosurgical evaluation regardless of GCS score 2
• Progressive symptoms (drowsiness, vomiting, declining GCS) indicate evolving mass effect and warrant surgical intervention 3, 4
• Standard surgical indications include hematoma thickness >10mm OR midline shift >5mm, but clinical deterioration overrides these imaging thresholds 3, 4

The French Society of Anaesthesia provides Grade 1+ recommendations that focal neurological deficits are high-risk features requiring immediate action, with urgent neurosurgical evaluation mandatory regardless of GCS. 2

Why Other Options Are Inappropriate

Intubation Alone (Option A) is Insufficient

Airway management without addressing the underlying surgical lesion will not prevent herniation or improve outcome. 1 While intubation is indicated for GCS ≤8, absent protective reflexes, or inability to maintain oxygenation 1, this child's GCS is above 8 and the primary problem is an expanding mass lesion requiring evacuation, not airway compromise.

• Intubation may be needed peri-operatively but is not the definitive management 1
• Delaying surgery to secure an airway in a non-obstructed patient wastes critical time 5

Reassurance (Option C) is Dangerous

Discharge or reassurance is completely inappropriate for any patient with documented subdural hematoma, focal neurological deficit, altered mental status, or declining GCS with intracranial pathology. 2, 6

• Even patients with GCS 15 and subdural hematoma require observation and potential intervention 6, 7
• This child has GCS <15 with progressive symptoms—reassurance would be negligent 2
• Warning signs that portend urgent intervention include vomiting, restlessness, any GCS decrease, and confusion—all present in this case 6

MRI (Option D) Delays Life-Saving Treatment

MRI has no role in the acute management of a child with known subdural hematoma and declining neurological status. 8

• CT has already established the diagnosis (crescent-shaped subdural hematoma) 8
• MRI is useful for persistent unexplained deficits after CT in the subacute/chronic phase, not for acute surgical decision-making 8
• Delaying surgery for additional imaging when the diagnosis is established increases morbidity and mortality 5

Surgical Timing and Technique

Surgical evacuation should be performed as soon as possible once the indication is established. 4, 5 While older data suggested that surgery within 4 hours improved outcomes 5, more recent evidence emphasizes that:

• The extent of primary brain injury and ability to control intracranial pressure are more critical than absolute surgical timing 5
• However, progressive deterioration mandates urgent intervention without delay 3, 4
• Craniotomy (with or without craniectomy) is the preferred technique over burr holes for acute subdural hematoma evacuation 4

Critical Supportive Measures During Preparation for Surgery

While arranging urgent neurosurgical intervention, maintain:

• Systolic blood pressure >110 mmHg to prevent secondary brain injury 1, 2
• Oxygen saturation ≥95% (SpO₂) or PaO₂ ≥98 mmHg 1
• Strict normocapnia (PaCO₂ 34-38 mmHg); avoid hyperventilation except for impending herniation 1
• Head of bed elevated 20-30° to improve venous drainage 1
• Serial neurological examinations every 15-30 minutes to detect further deterioration 1, 2

Common Pitfalls to Avoid

• Do not delay neurosurgical consultation for a "trial of observation" when progressive symptoms are present 2, 3
• Do not assume that GCS >8 means the patient is stable—progressive decline is the critical factor 2, 6
• Do not perform MRI or additional imaging when CT has already established a surgical diagnosis 8
• Do not discharge or reassure any child with documented subdural hematoma and neurological symptoms 2, 6
• A decline of ≥2 GCS points mandates immediate repeat head CT and expedited surgical evaluation 1, 4