In the emergency department, when should a neurosurgeon be consulted for a traumatic brain injury that may require urgent surgery? At the second Hainuyer de neurochirurgie (a regional neurosurgical meeting) held at the Royal Museum of Mariemont in Mariemont, Belgium, on April 9, 2026, Salim El Hadwe, MD, University of Cambridge, Cambridge, England, detailed the warning signs, and Anthony Nguyen, neurosurgeon, Tivoli University Hospital, La Louvière, Belgium, reviewed the main surgical techniques used to treat them.

“We speak of ‘traumatic brain injury’ when the skull or the brain is damaged because of an external force,” said El Hadwe. “For all types of traumatic brain injury, the most frequent symptoms are headache, nausea, vomiting, cognitive disturbances, and behavioral changes — such as a blank stare or drowsiness. Other classic signs, seen less often but important to know, are bruising around the ear or the eyes. These signs indicate a significant trauma. Other warning signs include high blood pressure with a slow heart rate and breathing problems, a focal neurologic deficit, seizures, or clonic activity, and, of course, clinical deterioration despite conservative treatment.”

The Glasgow Coma Scale

“The Glasgow Coma Scale (GCS) is a common clinical scale that helps determine the severity of the situation and the risk of death according to the patient’s level of consciousness and depth of coma,” El Hadwe continued. “The primary red flag is a falling GCS — particularly any score below 8. The goal when the GCS is 7 or 8 is to bring it back up to 12 to 15. Generally, everyone agrees that if the GCS is above 13, if the patient is not taking anticoagulants or antiplatelet agents, and if there is no loss of consciousness, the patient can be observed without a CT scan. But in most cases, we perform a cranial CT scan, and sometimes, an MRI is necessary.”

The Most Frequent Injuries

“Epidural hematomas carry a very high risk of mortality. These are collections of blood between the skull and the dura mater, often associated with a skull fracture. The information that must be communicated to the neurosurgeon for this situation includes, of course, the GCS, the patient’s pupillary status, current medications, comorbidities, age, and the radiologic findings. Our judgment will be based on these data. If the hematoma thickness is greater than 15 mm or the midline shift is more than 5 mm, we operate regardless of the GCS because there is a risk of deterioration. Naturally, if there is speech delay, motor deficit, or a seizure, we also operate. With epidural hematomas, it is typical for the patient to improve and then deteriorate, so it is very important to reassess every 15 to 30 minutes.”

A subdural hematoma is an accumulation of blood between the dura mater and the brain. “Depending on its severity and the time since formation, a subdural hematoma may be hyperdense or hypodense, but after trauma, it is often hyperdense. Sometimes patients have coagulation disorders, and it can therefore resemble a chronic hematoma. The information to convey is largely the same, but the criteria for drainage are a bit stricter: we operate when there is more than 10 mm of maximal thickness or 5 mm of midline shift.”

“A cerebral contusion is a traumatic lesion of the brain itself without a discrete blood collection; it behaves like an edema rather than a hematoma. Often, we see a hyperdense lesion at the point of contact with the skull, typically in the frontal or occipital region. Generally, the lesion enlarges, and the patient’s condition worsens 2 or 3 days after the injury.”

“All these brain lesions can cause brain herniation — displacement of brain tissue. Practically, when displacement occurs, it exerts pressure on the displaced tissue. Sometimes the patient’s clinical status and the CT findings do not match. One must always consider diffuse axonal injury, where rotational forces damage neurons. You may not see anything on CT because it is not sensitive enough, but you can see it on MRI. Generally, when the GCS is above 8, patients can speak and answer questions. They are then monitored either in stroke units or in intensive care. When the GCS falls below 8, communication with the patient is difficult, and we need more information. To evaluate shift, we can place an intracranial monitor, which shows what is happening inside the patient’s brain. We then treat with medications, protective measures, or surgery.”

Neurosurgical Techniques

After El Hadwe’s explanations, Nguyen presented “a summary of everything you might encounter in the operating room in cases of traumatic brain injury,” warning sensitive viewers about the graphic nature of some neurosurgical techniques.

Intracranial pressure monitoring. Sometimes after traumatic brain injury, imaging does not show drainable collections on CT even though the patient’s GCS is below 8, which meets the definition of coma. There can therefore still be elevated intracranial pressure despite the absence of identifiable hematomas. Several types of intracranial catheters allow measurement of intracranial pressure, including intraparenchymal catheters, subdural and extradural catheters — the latter are used much less because they are less effective — as well as, most frequently, the intraventricular catheter. The intraventricular catheter not only measures intracranial pressure but also allows drainage of cerebrospinal fluid to lower intracranial pressure if needed. This technique offers a modular collection system that allows clinicians to adjust the drainage threshold according to the pressure, the pathology, and the patient’s neurologic status.

Trephination. Trephination is used to place the catheters but also in some chronic subdural hematomas. It is important to distinguish between the two because the surgical technique is not the same. A trephination (burr) hole is usually made using a burr or a drill similar to a dental drill.

Craniotomy. Craniotomy — the surgical opening of the skull — accounts for the bulk of neurosurgical procedures. Techniques are individualized to the patient, the pathology, and the preoperative imaging. In traumatic brain injury, a large opening is required to treat epidural hematomas, acute subdural hematomas, intraparenchymal hematomas, or depressed skull fractures. Several anatomical layers must be traversed before reaching the brain: the skin, subcutaneous tissue and, depending on the site, the temporal muscle, the galea (the connective tissue over the skull), and then the bone. Beneath the bone lies the dura mater; opening the dura exposes the cerebral parenchyma, or the brain proper. Incision planning therefore always depends on the planned craniotomy and the individual patient. 

“There are certain principles to respect, notably the vascular supply to the scalp, to avoid any risk of postoperative necrosis,” Nguyen continued. “There is also an aesthetic aspect to consider. For example, if we want to avoid a frontal scar, we try to make the incision behind the hairline.”

Another indication for craniotomy is a depressed skull fracture. That is a fracture of the cranial vault, often associated with a subdural or epidural hematoma, or both, and sometimes with a corresponding scalp laceration. Not all such fractures require surgery, but when there is an overlying wound, you should consider it a covered fracture and therefore take the patient to the operating room to clean and debride the wound for optimal reconstruction. The other indication is if the depression of the fracture is at least equal to the thickness of the skull.

Decompressive craniectomy. Decompressive craniectomy is indicated when intracranial pressure is dangerously high. As pressure rises, the brain tends to shift downward toward the foramen magnum — the large skull opening through which the brainstem passes — a process known as herniation. Compression of the brainstem carries a risk for death because it controls heart and respiratory rates. The goal of decompressive craniectomy is to give the swollen brain room to expand outward, outside the skull. The bone flap is not replaced at the end of the procedure; the dura is closed, and the subcutaneous tissue and skin are sutured over it. The bone flap is reattached several months later, once the herniation has resolved.

This story was translated from MediQuality, part of the Medscape Professional Network.