Surgical decision-making in traumatic acute subdural hematoma: A scoping review of current evidence, knowledge gaps, and future directions

Background: Traumatic acute subdural hematoma (ASDH) is a major neurosurgical emergency associated with high morbidity and mortality. Despite numerous studies, uncertainty remains regarding optimal surgical decision-making. This scoping review aimed to map current evidence, identify knowledge gaps, and summarize factors influencing the surgical management of traumatic ASDH. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews-guided scoping review was conducted using PubMed and Scopus to identify studies published between January 2001 and July 2026. Studies involving adult patients with traumatic ASDH that evaluated surgical management or factors influencing surgical decision-making were included in the study. Data were extracted using a standardized framework and qualitatively synthesized. Results: Seventy-seven studies met the inclusion criteria. The current evidence showed no clear superiority of craniotomy over decompressive craniectomy in terms of mortality or functional outcomes. Admission Glasgow Coma Scale score, pupillary response, age, and frailty consistently influenced surgical decision-making and prognosis. Evidence supporting minimally invasive and endoscopic techniques remained limited. Important knowledge gaps included the lack of prospective comparative studies, inconsistent outcome reporting, and insufficient evidence to guide patient selection. Conclusion: No single surgical strategy is universally superior for traumatic ASDH. Surgical management should be individualized, with clinical, radiological, and patient-specific factors considered together. This review identifies important knowledge gaps and highlights priorities for future research to strengthen evidence-based surgical decision-making and improve patient outcomes.