Acute Traumatic Intracerebral Hematoma: To Operate or Not to Operate?

Acute traumatic intracerebral hematoma (TICH) is a severe complication of head injury, often associated with high morbidity and mortality. We report the case of a 44-year-old man admitted to the ED after a craniocerebral trauma caused by a fall from a tractor. On admission, he presented with impaired consciousness, scoring 8 on the Glasgow Coma Scale, with eye opening to pain (E2), incomprehensible verbal responses (V2), and withdrawal to painful stimuli (M4). Seizures and hemodynamic instability were also noted. CT revealed a large left frontal lobe hematoma with intraventricular and subarachnoid hemorrhage. In cooperation with the neurosurgical team, a decision was made to initiate conservative treatment in the ICU, focusing on airway protection, intracranial pressure control, hemodynamic stabilization, seizure prophylaxis, and infection prevention. During the following days, gradual clinical improvement was observed, with restoration of consciousness and regression of neurological deficits. Serial imaging demonstrated progressive resorption of the hematoma. The patient was discharged after 17 days in good general condition and transferred for rehabilitation, with only mild residual right lower limb weakness and minor cognitive impairment. This case highlights that, in selected patients, conservative management of TICH may lead to a favorable outcome despite extensive hemorrhage.