Traumatic brain injury continues to occupy a large share of emergency surgical and neurosurgical workload, and the burden is felt more sharply in low- and middle-income settings where road safety, pre-hospital care, referral delays and intensive care access remain uneven.[1] Globally, traumatic brain injury and spinal cord injury contribute substantially to death and disability, with consequences extending far beyond the first hospital admission.[2] Acute traumatic subdural haemorrhage is one of the most serious forms of intracranial bleeding after blunt head trauma. It is not merely a collection of blood over the cerebral convexity. It often marks a high-energy injury, associated cerebral contusion, raised intracranial pressure and secondary brain injury. Estimates of global traumatic brain injury incidence suggest that hospitals in countries such as India will continue to face a large volume of cases needing rapid triage and definitive imaging.[3] Management decisions in acute subdural haemorrhage are guided by a combination of clinical status and computed tomography findings. Widely used surgical guidance recommends evacuation when acute subdural haematoma thickness exceeds 10 mm or midline shift exceeds 5 mm, regardless of admission GCS, while comatose patients require still closer monitoring and rapid decision-making.[4] In practice, the same CT measurement may carry different prognostic meaning depending on the patient’s age, pupillary reaction, timing of presentation and associated systemic injury. The Glasgow Coma Scale remains the most familiar language for communicating admission neurological severity in head injury, despite its limitations in sedated, intubated or intoxicated patients.[5] Functional outcome is commonly documented using the Glasgow Outcome Scale, which separates death, vegetative survival, severe disability, moderate disability and good recovery in a clinically interpretable manner.[6] These two simple bedside scales continue to retain value because they can be applied even in busy casualty and emergency operating room pathways. Current literature on acute subdural haematoma emphasises that operative treatment is necessary for many patients, but surgery alone cannot neutralise the effect of poor preoperative neurological status.[7] Recent trial evidence has also renewed discussion on the choice between craniotomy and decompressive craniectomy for traumatic acute subdural haematoma, showing that operative strategy has to be individualised rather than chosen mechanically.[8] Indian district and teaching hospitals face a particular challenge: patients often arrive after road traffic accidents from rural roads, two-wheeler crashes, falls at home or workplace injuries, sometimes after initial care elsewhere. The present study was undertaken to evaluate the clinical profile, management pattern, complications and short-term functional outcome of patients with acute traumatic subdural haemorrhage treated at a service hospital in Tamil Nadu.

Study design and setting This was a hospital-based observational study conducted in the Department of General Surgery, Government Medical College and Hospital, Kallakurichi, Tamil Nadu, India. Study period and sample size The study was carried out from July to November 2024. A total of 74 patients with acute traumatic subdural haemorrhage were included. Study population Patients managed for acute traumatic subdural haemorrhage during the study period were evaluated. The analysis was restricted to traumatic cases with documented admission neurological status, radiological measurements, management details and short-term outcome assessment. Clinical and radiological variables The variables recorded were age, sex, mode of injury, admission GCS, pupillary status, haematoma thickness, midline shift, management modality, type of surgery, complications, GOS at discharge and GOS at one-month follow-up. Admission GCS was categorised as severe (3-8), moderate (9-12) and mild (13-15). Management and follow-up Management was classified as surgical or conservative. Surgical procedures included decompressive craniectomy, craniotomy with evacuation and burr hole evacuation. Short-term functional status was assessed at discharge and again at one-month follow-up using GOS. Outcome definition The primary outcome was one-month functional outcome. GOS 4-5 was considered favourable, while GOS 1-3 was considered unfavourable. Secondary observations included discharge GOS, complications and change in GOS between discharge and one month. Ethical considerations The ethics approval was obtained prior to this study. Patient confidentiality was maintained during analysis and reporting. Statistical analysis Continuous variables were summarised as mean ± standard deviation with range. Categorical variables were expressed as frequency and percentage. Associations between clinical factors and one-month outcome were assessed using Chi-square test or Fisher’s exact test as appropriate. Paired change in GOS from discharge to one month was assessed using Wilcoxon signed-rank test. A p-value <0.05 was considered statistically significant

Baseline profile and mechanism of injury The study included 74 patients with acute traumatic subdural haemorrhage. The mean age was 50.54 ± 19.06 years, with an age range of 19 to 79 years. Males constituted 55 patients (74.32%). Road traffic accident was the leading mechanism of injury, accounting for 44 cases (59.46%), followed by fall in 23 (31.08%) and assault in 7 (9.46%). Severe admission GCS was present in 45 patients (60.81%). Reactive pupils were documented in 30 patients (40.54%), fixed pupils in 27 (36.49%) and sluggish reaction in 17 (22.97%) (Table 1 and Figure 1). Table 1. Baseline clinical profile of the study population (n=74). Variable Frequency / Mean ± SD Range Age, years 50.54 ± 19.06 19–79 ≤40 years 26 (35.14) 41–60 years 21 (28.38) >60 years 27 (36.49) Male 55 (74.32) Female 19 (25.68) Road traffic accident 44 (59.46) Fall 23 (31.08) Assault 7 (9.46) Severe GCS (3–8) 45 (60.81) Moderate GCS (9–12) 17 (22.97) Mild GCS (13–15) 12 (16.22) Reactive pupils 30 (40.54) Sluggish pupils 17 (22.97) Fixed pupils 27 (36.49) GCS: Glasgow Coma Scale; SD: standard deviation. Donut chart displays the proportion and number of patients in each injury category. Radiological severity and management The mean haematoma thickness was 14.63 ± 5.73 mm and the mean midline shift was 8.07 ± 4.25 mm. Haematoma thickness greater than 15 mm was observed in 35 patients (47.30%), while midline shift greater than 10 mm was noted in 28 patients (37.84%). Surgical management was undertaken in 73 patients (98.65%). Decompressive craniectomy was performed in 34 patients (45.95%), craniotomy with evacuation in 30 (40.54%) and burr hole evacuation in 9 (12.16%) (Table 2). Table 2. Radiological profile and management pattern (n=74). Variable Frequency / Mean ± SD Range Haematoma thickness, mm 14.63 ± 5.73 5.3–24.6 <10 mm 20 (27.03) 10–15 mm 19 (25.68) >15 mm 35 (47.30) Midline shift, mm 8.07 ± 4.25 0.6–14.9 ≤5 mm 20 (27.03) >5–10 mm 26 (35.14) >10 mm 28 (37.84) Surgical management 73 (98.65) Conservative management 1 (1.35) Decompressive craniectomy 34 (45.95) Craniotomy and evacuation 30 (40.54) Burr hole evacuation 9 (12.16) No surgery 1 (1.35) Radiological variables are reported in millimetres. Short-term outcome and complications At discharge, 31 patients (41.89%) had a favourable outcome (GOS 4-5), while 43 (58.11%) had an unfavourable outcome (GOS 1-3). At one-month follow-up, favourable outcome increased to 35 patients (47.30%). GOS improved between discharge and one month in 9 patients (12.16%), remained unchanged in 65 (87.84%) and worsened in none; the paired change was statistically significant (Wilcoxon p=0.0027). Mortality at one month was 9 patients (12.16%). The recorded complication profile included seizures in 17 (22.97%), pneumonia in 17 (22.97%) and surgical site infection in 12 (16.22%); 28 patients (37.84%) had no recorded complication (Table 3, Figure 4 and Figure 5). Table 3. Glasgow Outcome Scale distribution and complications (n=74). Outcome / complication Frequency (%) Interpretation GOS 1 at discharge 9 (12.16) Death GOS 2 at discharge 16 (21.62) Vegetative state GOS 3 at discharge 18 (24.32) Severe disability GOS 4 at discharge 10 (13.51) Moderate disability GOS 5 at discharge 21 (28.38) Good recovery Favourable discharge outcome (GOS 4-5) 31 (41.89) Unfavourable discharge outcome (GOS 1-3) 43 (58.11) GOS 1 at one month 9 (12.16) Death GOS 2 at one month 13 (17.57) Vegetative state GOS 3 at one month 17 (22.97) Severe disability GOS 4 at one month 12 (16.22) Moderate disability GOS 5 at one month 23 (31.08) Good recovery Favourable one-month outcome (GOS 4-5) 35 (47.30) Unfavourable one-month outcome (GOS 1-3) 39 (52.70) No recorded complication 28 (37.84) Seizures 17 (22.97) Pneumonia 17 (22.97) Surgical site infection 12 (16.22) Pie chart shows the distribution of recorded complication categories. Factors associated with one-month outcome On factor-wise analysis, severe admission GCS and fixed pupillary status showed the clearest relationship with unfavourable one-month outcome. Among patients with GCS 3-8, 39 of 45 (86.67%) had an unfavourable outcome, compared with none among those with GCS 9-15. Fixed pupils were associated with unfavourable outcome in 24 of 27 patients (88.89%). Both associations were statistically significant (p<0.0001). Age above 60 years, sex, road traffic accident mechanism, haematoma thickness greater than 15 mm, midline shift greater than 10 mm, decompressive craniectomy and recorded complications were not statistically significant predictors in this cohort (Table 4, Figure 2 and Figure 3). Table 4. Selected factors associated with one-month functional outcome. Factor Favourable outcome Unfavourable outcome p-value Age >60 years 11/27 (40.74) 16/27 (59.26) 0.4714 Male sex 25/55 (45.45) 30/55 (54.55) 0.6062 Road traffic accident 25/44 (56.82) 19/44 (43.18) 0.0597 Severe GCS (3–8) 6/45 (13.33) 39/45 (86.67) <0.0001 Fixed pupil 3/27 (11.11) 24/27 (88.89) <0.0001 Hematoma thickness >15 mm 15/35 (42.86) 20/35 (57.14) 0.4939 Midline shift >10 mm 14/28 (50.00) 14/28 (50.00) 0.8118 Decompressive craniectomy 14/34 (41.18) 20/34 (58.82) 0.3594 Any complication 20/46 (43.48) 26/46 (56.52) 0.4747 Favourable outcome: GOS 4-5; unfavourable outcome: GOS 1-3. p-values were calculated using Fisher’s exact test for 2 x 2 comparisons.

This study examined a focused group of 74 patients with acute traumatic subdural haemorrhage and followed functional status up to one month. The pattern is clinically familiar for a public sector trauma-receiving hospital in Tamil Nadu: middle-aged and elderly patients, male predominance, a high contribution from road traffic accidents, and a large proportion presenting with severe GCS. Nearly all patients required operative management. The central finding is straightforward, but important. Admission GCS and pupillary status were much more closely linked to short-term outcome than age, mechanism, haematoma thickness, midline shift or type of operation. The strong relationship between admission GCS and outcome has been repeatedly described in acute subdural haematoma literature. Koç and colleagues reported that patients with higher GCS scores had better functional recovery, while poor admission neurological status carried a heavy mortality burden.[9] The present findings move in the same direction: all patients with GCS 9-15 achieved a favourable one-month outcome, whereas most patients with GCS 3-8 remained in the unfavourable group. This does not mean surgery is futile in severe GCS patients. It means counselling must be honest and early physiological optimisation must not be delayed. Operative timing and aggressive evacuation have long been debated in acute subdural haematoma. Wilberger and colleagues highlighted the morbidity and mortality associated with acute subdural haematoma and brought attention to the urgency of clot removal in surgically selected patients.[10] In a district-linked Indian setting, the time clock starts before hospital arrival. Ambulance availability, transfer from peripheral centres, CT access, family consent and operating room readiness all influence the practical interval between injury and evacuation. These realities rarely appear in a table, but they shape outcome. Pupillary status was the other decisive clinical marker. Fixed pupils were associated with unfavourable outcome in nearly nine out of ten patients. Karasu et al. also identified admission GCS and pupillary abnormality among the most important determinants of prognosis in operated traumatic acute subdural haematoma.[11] Pupillary non-reactivity is often a late sign in raised intracranial pressure pathways, and its presence should trigger urgent escalation rather than a wait-and-watch approach. In the present study, sluggish pupils behaved as an intermediate state, which is clinically sensible. Indian single-centre data have similarly shown that acute subdural haematoma outcome is shaped by GCS, pupillary findings and the severity of primary brain injury. Arumugam and colleagues, in a South Indian analysis, described outcome heterogeneity even among operated patients, reinforcing that acute subdural haematoma is not a uniform surgical entity.[12] That observation is useful here because 98.65% of patients in the present cohort underwent surgery, leaving little room to compare conservative and operative pathways. Radiological severity deserves a more cautious reading. Haematoma thickness and midline shift are essential for triage and operative indication, but neither showed a statistically significant association with one-month outcome in this cohort. This should not be misread as radiology being unimportant. Rather, the cohort was heavily weighted towards surgical cases, many already crossing conventional thresholds. Recent reviews have emphasised that CT variables, age, anticoagulation status, systemic insults, neurological grade and operative timing interact with each other, and a single imaging cut-off rarely captures the whole prognosis.[13] The distribution of surgical procedures also reflects real-world decision-making. Decompressive craniectomy was slightly more common than craniotomy with evacuation. Recent evidence from the RESCUE-ASDH trial and observational CENTER-TBI analysis has shown that the choice between decompressive craniectomy and craniotomy is nuanced, with disability outcomes, reoperation risk, intracranial pressure concerns and wound-related issues all entering the decision.[14] The present study was not designed to compare these procedures directly. More severely injured patients are often selected for decompressive craniectomy, so crude outcome comparison can be misleading. The one-month outcome showed a modest but statistically significant improvement from discharge, with no patient worsening during early follow-up. This finding is encouraging but should be interpreted within a short observation window. In studies from resource-constrained environments, acute subdural haematoma continues to carry a high burden of death and disability, and early survival does not always translate into full independence.[15] Rehabilitation, seizure control, chest care and wound care become especially relevant after discharge, where family members often carry much of the practical burden. Complications were not statistically associated with one-month outcome here, although seizures, pneumonia and surgical site infection were common enough to matter clinically. A larger sample may show clearer relationships. Recent traumatic brain injury commission updates stress that improving outcome requires systems of care: prevention, rapid transfer, standardised acute management, critical care protocols and rehabilitation access.[16] For hospitals such as Kallakurichi, even simple steps such as fast CT pathways, early neurosurgical coordination, ICU bed prioritisation and structured discharge counselling can have meaningful value. The study has limitations. The sample size was modest and the study was conducted at a single centre. Follow-up was limited to one month, so delayed seizures, persistent disability, cognitive recovery, return to work and late complications could not be assessed. Almost all patients underwent surgery, limiting meaningful comparison between operative and conservative management. The analysis used GOS rather than an extended structured outcome interview. Despite these constraints, the study provides a practical picture of acute traumatic subdural haemorrhage management in a service hospital and identifies admission GCS and pupillary reaction as the most useful short-term prognostic markers

In patients with acute traumatic subdural haemorrhage, short-term functional outcome was most strongly associated with admission GCS and pupillary status. Road traffic accident was the leading mechanism of injury, and almost all patients required operative intervention. Decompressive craniectomy and craniotomy with evacuation were the predominant surgical procedures. Although favourable outcome increased from discharge to one month, more than half of the cohort still had GOS 1-3 at one-month follow-up. Early neurological assessment, rapid imaging, timely surgical decision-making and structured post-discharge follow-up remain central to improving outcomes

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