ArticleInternational journal of surgery case reports2026
Emergency burr-hole evacuation for subacute SDH with uncal herniation: a case report of near-complete neurological recovery despite bilateral occipital infarction.
Article in International journal of surgery case reports, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction and importance: Subacute subdural hematoma (SDH) can remain clinically silent before progressing to fatal herniation. Bilateral fixed dilated pupils in the setting of SDH are traditionally regarded as a near-terminal sign, associated with poor outcomes. Reports of near-complete neurological recovery despite established uncal herniation remain exceedingly rare. This case highlights the importance of rapid decompression as a "brain code" intervention in potentially reversible mass lesions. Case presentation: A previously healthy 47-year-old woman presented with a 2-week history of worsening headaches and intermittent confusion. Initial CT imaging revealed a left frontoparietal subacute SDH with a significant midline shift. While preparing for emergent evacuation, she experienced an abrupt neurological collapse, developing a Glasgow Coma Scale of 3 and bilateral fixed dilated pupils. Immediate burr-hole evacuation resulted in rapid brain relaxation. Postoperatively, she regained full consciousness with a near-complete neurological recovery; however, an MRI confirmed bilateral occipital infarctions resulting in permanent cortical visual impairment. Clinical discussion: This case emphasizes that timely intervention can reverse the physiology of herniation before irreversible brainstem ischemia occurs. While bilateral fixed pupils have been regarded as a sign of futility, aggressive early decompression may provide meaningful recovery in carefully selected patients, especially when deterioration is witnessed and the time to surgery is minimal. Conclusion: Rapid burr-hole evacuation can reverse impending uncal herniation from subacute SDH and result in unexpected but meaningful neurological outcomes in selected patients when deterioration is witnessed and decompression is performed ultra-early. Fixed dilated pupils should not automatically preclude aggressive intervention when the underlying cause is promptly treatable.
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