Blown-pupil subdural with contusion — flap choice, TXA timing, pressure ladder and 24-month counsel

Model answer

• Evacuate: blown pupil with 8 mm shift and coma is mass effect with deterioration — a true neurosurgical emergency, not an equipoise case.^[13]
• Equipoise boundary: where the surgeon genuinely hesitates, centre preference for acute surgery (0-86% of cases) changes nothing (OR 1.05), so conservative care with delayed-surgery safety net (12% convert) is defensible.^[13]
• Flap: RESCUE-ASDH (450 randomised) found no functional difference (common OR 0.85, null) with deaths 30.2 vs 32.2% — replace the flap unless intraoperative swelling forbids it; craniotomy risks re-operation, craniectomy risks wound failure.^[5]
• TXA: 1 g over 10 min then 1 g over 8 h within 3 h (CRASH-3: head-injury death 18.5 vs 19.8%, mild-moderate RR 0.78, vessels neutral) — optimal within 2 h or with GCS below 9.^[18][19]
• Pressure: monitor the severe brain (BEST-TRIP ICP-at-or-below-20 protocol equals imaging-exam care, so the number informs rather than commands); climb SIBICC tiers 10-4-3; rescue doorway is sustained pressure above 25 for 1-12 h despite therapy.^[9][7][2]
• Seizure: phenytoin load within 24 h for 7 days — week-1 seizures 3.6 vs 14.2% (RR 0.27), no late effect (Cochrane late RR 0.91) — then stop.^[29][30]
• VTE: pharmacologic prophylaxis within 72 h on a stable 24-h scan — early beats late (OR 0.46) with no safety difference.^[37]
• Counsel: per 100 rescue operations, 21 extra alive at 24 months — 4 vegetative, 9 severely disabled, 8 moderately disabled, none extra fully recovered — with a third of surgical survivors still improving between 6 and 24 months.^[3]