Surgical decision-making in traumatic acute subdural hematoma: A scoping review of current evidence, knowledge gaps, and future directions

Abstract

Background:

Traumatic acute subdural hematoma (ASDH) is a major neurosurgical emergency associated with high morbidity and mortality. Despite numerous studies, uncertainty remains regarding optimal surgical decision-making. This scoping review aimed to map current evidence, identify knowledge gaps, and summarize factors influencing the surgical management of traumatic ASDH.

Methods:

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews-guided scoping review was conducted using PubMed and Scopus to identify studies published between January 2001 and July 2026. Studies involving adult patients with traumatic ASDH that evaluated surgical management or factors influencing surgical decision-making were included in the study. Data were extracted using a standardized framework and qualitatively synthesized.

Results:

Seventy-seven studies met the inclusion criteria. The current evidence showed no clear superiority of craniotomy over decompressive craniectomy in terms of mortality or functional outcomes. Admission Glasgow Coma Scale score, pupillary response, age, and frailty consistently influenced surgical decision-making and prognosis. Evidence supporting minimally invasive and endoscopic techniques remained limited. Important knowledge gaps included the lack of prospective comparative studies, inconsistent outcome reporting, and insufficient evidence to guide patient selection.

Conclusion:

No single surgical strategy is universally superior for traumatic ASDH. Surgical management should be individualized, with clinical, radiological, and patient-specific factors considered together. This review identifies important knowledge gaps and highlights priorities for future research to strengthen evidence-based surgical decision-making and improve patient outcomes.

INTRODUCTION

Traumatic acute subdural hematoma (ASDH) represents a major neurosurgical emergency and remains a leading cause of morbidity and mortality following traumatic brain injury (TBI).[28,60] It occurs in a substantial proportion of patients with TBI requiring neurosurgical intervention and is frequently associated with rapid neurological deterioration due to mass effect, increased intracranial pressure (ICP), and secondary brain injury. Despite advances in neurocritical care and surgical techniques, mortality among surgically treated patients remains high, ranging from 30% to 60%.[4,19,57]

Early clinical assessment is fundamental to prognostication and surgical decision-making. Among the numerous prognostic variables, admission Glasgow Coma Scale (GCS) score and pupillary response are consistently recognized as the strongest predictors of mortality and functional outcome.[6,13,16,74] In addition, patient-related factors, particularly advanced age and frailty, substantially influence treatment selection, perioperative risk, and long-term recovery.[4,18,57,76]

Although numerous observational studies, systematic reviews, and meta-analyses have evaluated the surgical management of traumatic ASDH, the optimal surgical strategy remains controversial.[28,49,51] The primary surgical decision involves choosing between craniotomy, in which the bone flap is replaced after hematoma evacuation, and decompressive craniectomy (DC), in which the bone flap is intentionally left unreplaced to accommodate cerebral swelling. However, direct comparisons between these surgical approaches are complicated by substantial clinical heterogeneity, differences in patient selection, and the tendency to reserve DC for patients with more severe neurological injury. Consequently, the available evidence should be interpreted with caution, as treatment allocation is frequently influenced by injury severity and surgeon preference, limiting the validity of direct comparisons between surgical strategies.

Growing interest has emerged in minimally invasive and endoscopic evacuation techniques, particularly for elderly patients and those with significant comorbidities.[29,35,43,75] However, the current evidence is limited and heterogeneous, consisting predominantly of retrospective studies with relatively small sample sizes. Accordingly, the role of these techniques in routine neurosurgical practice has yet to be clearly established.

Despite the availability of several systematic reviews and meta-analyses addressing individual aspects of traumatic ASDH management, important uncertainties persist regarding patient selection, integration of prognostic factors into surgical decision-making, and the role of emerging surgical techniques. Moreover, existing reviews have primarily focused on comparisons between surgical procedures rather than providing an integrated overview of the broader clinical decision-making process or highlighting persistent evidence gaps. Therefore, this study was conducted to systematically map the current evidence, identify knowledge gaps, and synthesize clinically relevant factors influencing surgical decision-making in traumatic ASDH. By integrating evidence across surgical strategies, prognostic factors, perioperative management, and novel therapeutic approaches, the present review provides a practical framework for evidence-based neurosurgical decision-making while highlighting priorities for future clinical research.

METHODS

Search strategy and study design

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. A systematic literature search was performed in PubMed and Scopus to identify studies evaluating the surgical management of traumatic ASDH. The search included publications from January 2001 to July 2026 and was restricted to English-language studies involving human subjects. The PubMed search used combinations of the terms ASDH, traumatic ASDH, traumatic subdural hematoma, craniotomy, DC, surgery, surgical, evacuation, and endoscopic, searched within the Title/Abstract fields. An equivalent TITLE-ABS-KEY strategy was applied in Scopus. In addition, the reference lists of all eligible studies were manually screened to identify further relevant publications.

Eligibility criteria

Studies were eligible if they included adult patients with traumatic ASDH and evaluated surgical management or factors influencing surgical decision-making. Eligible study designs comprised randomized controlled trials, prospective and retrospective cohort studies, comparative studies, and observational studies reporting clinically relevant outcomes. Studies involving chronic, spontaneous, aneurysmal, or non-traumatic subdural hematomas; pediatric populations; case reports or case series involving fewer than five patients; review articles; editorials; conference abstracts; technical notes without original clinical outcome data; and non-English publications were excluded from the study.

Study selection and data extraction

Records retrieved from PubMed and Scopus were imported into Zotero reference management software, where duplicate records were identified and removed before screening. Titles and abstracts were screened for eligibility, followed by full-text assessment of potentially relevant studies. Data were extracted using a predefined framework that included study design, publication year, patient characteristics, surgical approach, prognostic factors, and clinical outcomes. The included studies were subsequently categorized into predefined thematic domains, including operative indications, comparisons between craniotomy and DC, prognostic models, minimally invasive techniques, perioperative considerations, and special patient populations.

Data synthesis

Given the substantial heterogeneity in study design, patient populations, surgical interventions, and reported outcomes, quantitative meta-analysis was not appropriate. Therefore, the findings were synthesized descriptively according to predefined thematic categories to map the breadth of the available evidence, identify knowledge gaps, and summarize contemporary approaches to surgical decision-making in traumatic ASDH.

RESULTS

Study selection

The literature search identified 652 records, including 454 from PubMed and 198 from Scopus. After removal of duplicate records, 531 unique records remained for title and abstract screening, of which 445 were excluded from the study. The full texts of 86 potentially eligible studies were assessed for eligibility, and nine studies were excluded for the following reasons: Chronic or spontaneous subdural hematoma (n = 3), case reports or small case series (n = 2), review articles or editorials (n = 2), and insufficient clinical outcome data (n = 2). Ultimately, 77 studies met the eligibility criteria and were included in the qualitative synthesis. The study selection process is illustrated in Figure 1, and the characteristics of the included studies are summarized in Tables 1-5.

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram illustrating the study selection process for this scoping review.

Table 1:

Characteristics of included studies.

Table 5:

Special populations and perioperative considerations in traumatic acute subdural hematoma.

Study characteristics

Seventy-seven studies published between January 2001 and July 2026 consisted predominantly of retrospective observational cohort studies, together with prospective multicenter investigations, randomized controlled trials, study protocols, and comparative observational studies. Collectively, they encompassed a broad spectrum of adult patients with traumatic ASDH undergoing surgical treatment across North America, Europe, and Asia. The principal research themes included comparisons between craniotomy and DC, identification of prognostic factors associated with mortality and functional recovery, evaluation of minimally invasive and endoscopic surgical techniques, management of elderly and frail patients, perioperative considerations, optimization of surgical timing, and the development of imaging-based prediction models and decision-support tools. For clarity, the evidence was organized into five thematic categories covering overall study characteristics, comparisons of craniotomy versus DC, prognostic models, minimally invasive techniques, and special populations with perioperative considerations [Tables 1-5]. Table 1 summarizes the characteristics of the included studies.

Surgical strategies: Craniotomy versus DC

Most included studies evaluated craniotomy and DC as the principal surgical strategies for traumatic ASDH. Across studies, procedure selection was consistently influenced by admission neurological status, radiological severity (including hematoma thickness, midline shift, and basal cistern compression), intraoperative brain swelling, and the anticipated risk of postoperative intracranial hypertension. Recent high-level evidence, including the RESCUE-ASDH randomized controlled trial, demonstrated no clear superiority of DC over craniotomy with respect to long-term functional outcomes or mortality. However, DC was associated with a higher incidence of wound-related complications and a greater need for subsequent cranioplasty. Similarly, multiple retrospective cohort studies, propensity score-matched analyses, and multicenter observational investigations have shown that surgical outcomes are determined primarily by patient selection and injury severity rather than by the surgical technique itself. Collectively, the current evidence supports an individualized approach to surgical decision-making, with procedure selection guided by admission neurological status, radiological severity, anticipated cerebral swelling, and intraoperative findings rather than by a universal preference for either technique [Table 2].

Table 2:

Major studies comparing craniotomy and decompressive craniectomy in traumatic acute subdural hematoma.

Prognostic factors

Multiple clinical, radiological, and perioperative factors were consistently associated with mortality and functional outcomes. Advanced age, frailty, low admission GCS score, bilaterally nonreactive pupils, greater hematoma thickness, marked midline shift, basal cistern compression, anticoagulant or antithrombotic therapy, coagulopathy, thrombocytopenia, and diffuse intraoperative brain swelling were identified as major predictors of unfavorable outcomes. Several studies further demonstrated that delayed surgical intervention, severe preoperative neurological impairment, and postoperative cerebral infarction were independently associated with poorer functional recovery. Recent investigations have introduced several validated prognostic tools, including the Richmond ASDH Score, tASDH Risk Score, imaging-based nomograms, Rotterdam computed tomography (CT) score-based models, radiomics approaches, and machine-learning prediction models. Taken together, these findings underscore the growing role of multivariable risk stratification and advanced imaging analysis in supporting individualized surgical decision-making and prognostic assessment [Table 3].

Table 3:

Prognostic factors and prediction models for traumatic acute subdural hematoma.

Minimally invasive surgical techniques

Several studies evaluated minimally invasive surgical approaches, including endoscopic hematoma evacuation through burr holes or small craniotomies, burr hole decompression followed by elective craniotomy under ICP monitoring, and other limited-access techniques. These approaches were primarily applied in carefully selected elderly patients and individuals with significant medical comorbidities who were considered poor candidates for conventional craniotomy. Compared with conventional surgery, minimally invasive techniques were generally associated with shorter operative times, reduced intraoperative blood loss, less surgical trauma, and acceptable neurological outcomes in appropriately selected patients. However, the available evidence is derived predominantly from single-center retrospective studies with relatively small sample sizes, limiting the generalizability of these findings. Therefore, routine use of minimally invasive techniques cannot currently be recommended, and well-designed prospective comparative studies are required to better define their indications and long-term outcomes. At present, these approaches should be regarded as complementary rather than replacement strategies for conventional surgery in carefully selected patients [Table 4].

Table 4:

Minimally invasive and endoscopic surgical techniques for traumatic acute subdural hematoma.

Special populations and perioperative considerations

Special clinical scenarios have received increasing attention in recent years. Older adults, particularly octogenarians and nonagenarians, represent one of the most extensively investigated patient populations. Although mortality remains high in these patients, several studies have demonstrated that carefully selected individuals can achieve meaningful functional recovery following surgical intervention, indicating that chronological age alone should not preclude surgery. Increasing evidence also emphasizes the importance of frailty, pre-injury functional status, and overall physiological reserve in selecting surgical candidates. Additional studies have evaluated perioperative management in patients receiving anticoagulant or antithrombotic therapy, reversal strategies, thrombocytopenia, biomarkers associated with postoperative cerebral infarction, readmission risk, postoperative complications, and healthcare resource utilization. These findings reinforce the importance of individualized patient selection and multidisciplinary perioperative management, particularly in elderly and medically complex patients [Table 5].

Overall evidence synthesis

Current evidence demonstrates a gradual evolution in the surgical management of traumatic ASDH over the past two decades. Contemporary evidence increasingly supports individualized surgical decision-making that integrates clinical presentation, neurological status, radiological severity, patient frailty, and validated prognostic models rather than relying solely on isolated radiographic thresholds. Nevertheless, substantial heterogeneity persists with respect to patient selection, surgical indications, operative techniques, perioperative management, and outcome reporting, limiting direct comparisons across studies. These findings emphasize the need for high-quality prospective multicenter studies and additional randomized controlled trials to further strengthen evidence-based surgical decision-making.

DISCUSSION

Traumatic ASDH remains one of the most severe forms of TBI and continues to be associated with substantial mortality and long-term disability despite advances in neurocritical care and surgical techniques. Although surgical evacuation has long been accepted as the standard treatment for patients with significant mass effect or neurological deterioration, the optimal surgical strategy remains controversial.[28] This scoping review synthesizes more than two decades of evidence and demonstrates a progressive shift from rigid radiological thresholds toward individualized, evidence-based surgical decision-making.

One of the principal findings of the present review is that surgical outcomes depend more on appropriate patient selection than on the surgical technique itself. While DC provides superior ICP control in patients with severe cerebral swelling, conventional craniotomy preserves cranial integrity and avoids the need for subsequent cranioplasty. The RESCUE-ASDH randomized trial represents a major milestone in this field, demonstrating comparable functional outcomes between DC and craniotomy while showing higher rates of wound-related complications and subsequent cranioplasty in the DC group.[28] These findings support an individualized surgical approach rather than a routine preference for either technique [Figure 2].

Figure 2:

Proposed evidence-based clinical decision tree for individualized surgical decision-making in traumatic acute subdural hematoma.

Another important observation across the reviewed studies is the central role of preoperative neurological and radiological assessment. Admission GCS score, pupillary reactivity, age, degree of midline shift, basal cistern compression, and diffuse cerebral swelling were identified as the most robust predictors of mortality and functional outcome. More recently, prognostic assessment has evolved through the incorporation of imaging biomarkers, validated clinical risk scores, radiomics, CT densitometry, and machine-learning-based prediction models.[6,13,16,31,74] These developments have the potential to improve risk stratification and facilitate more individualized surgical planning.

The management of elderly patients warrants special consideration. Historically, advanced age was frequently regarded as a relative contraindication to aggressive surgical intervention. However, several contemporary multicenter studies have demonstrated that carefully selected elderly patients may achieve meaningful functional recovery following surgical evacuation, particularly when a favorable preoperative neurological status is preserved. Accordingly, chronological age should no longer be considered sufficient justification for withholding surgery. Instead, treatment decisions should be based on a comprehensive assessment of frailty, premorbid functional status, comorbidities, neurological examination, and patient preferences.[4,15,18,57,76]

An additional trend identified in recent years is the growing interest in minimally invasive surgical techniques. Endoscopic evacuation through burr holes or limited craniotomies has shown encouraging results in elderly and medically fragile patients, offering shorter operative times, reduced blood loss, and lower surgical morbidity. The evidence remains largely retrospective and is limited to highly selected patient populations.[14,26,29,34,35,41,75] Well-designed prospective multicenter comparative studies are still required before these approaches can be recommended as standard treatment. They should be regarded as complementary rather than replacement strategies for conventional surgery in appropriately selected patients.

Perioperative optimization has become an increasingly important component of traumatic ASDH management. Appropriate management of anticoagulant and antiplatelet therapy, correction of coagulopathy, prevention of secondary brain injury, postoperative ICP control, and early recognition of complications all substantially influence clinical outcomes.[11,23,24,54,63] Emerging biomarkers and individualized management strategies may further enhance recovery while reducing secondary neurological injury. Taken together, these findings suggest that comprehensive perioperative management is likely to optimize patient outcomes.

Despite these advances, several important limitations remain in the current evidence. Most studies are retrospective and therefore susceptible to selection bias and institutional treatment preferences. In addition, publication bias and variability in treatment protocols across institutions may have influenced the overall body of evidence. Considerable heterogeneity exists in inclusion criteria, surgical indications, operative techniques, outcome measures, and follow-up duration, limiting direct comparisons between studies. Furthermore, randomized controlled trials remain scarce despite the substantial clinical burden of traumatic ASDH.

Nevertheless, this study provides a comprehensive overview of contemporary evidence while identifying key knowledge gaps relevant to clinical practice and future research. By integrating findings from randomized trials, multicenter cohort studies, prognostic modeling investigations, and emerging minimally invasive techniques, it offers a practical approach to individualized surgical decision-making. Future studies should prioritize prospective multicenter randomized trials, external validation of prediction models, incorporation of artificial intelligence-assisted decision-support systems, and standardized outcome reporting to optimize patient selection and improve long-term neurological outcomes.

Strengths and limitations

The principal strength of this review lies in its comprehensive evaluation of evidence spanning more than two decades, encompassing randomized controlled trials, multicenter observational studies, prognostic models, and emerging surgical techniques. The scoping review methodology enabled systematic mapping of the literature, identification of key knowledge gaps, and integration of diverse evidence relevant to surgical decision-making in traumatic ASDH.

This study has several limitations. Only English-language studies indexed in PubMed and Scopus were included, which may have introduced language and publication bias. In addition, variability in institutional treatment protocols and patient selection strategies across studies may have influenced the overall body of evidence. Due to substantial heterogeneity in study design, patient characteristics, surgical indications, operative techniques, and reported outcomes, quantitative meta-analysis was not appropriate. The findings should be interpreted as a comprehensive evidence map rather than a pooled estimate of treatment effect.

CONCLUSION

Traumatic ASDH remains one of the most critical neurosurgical emergencies. The current evidence does not support the universal superiority of any single surgical strategy. Instead, surgical management should be tailored by integrating neurological status, radiological severity, patient frailty, anticipated cerebral swelling, and the overall clinical context. Overall, the available evidence supports individualized, evidence-based surgical decision-making informed by validated prognostic models and comprehensive clinical assessment rather than isolated radiographic criteria alone. Future high-quality multicenter randomized trials, external validation of prognostic models, and the development of artificial intelligence-assisted decision-support tools may help refine patient selection, optimize surgical strategies, and improve long-term neurological outcomes in patients with traumatic ASDH.

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

Patient’s consent was not required as there are no patients in this study.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.