Treatment of acute subdural haematoma – Authors' reply

[...]Beucler suggests that delayed surgery could be regarded as acute surgery and should not have been analysed in the conservative treatment group. The SHE score is a prediction tool that should not be used to triage treatment—the extensively validated IMPACT and CRASH-CT models are superior in this respect. [...]the SHE score has limited value as a prediction tool for acute subdural haematoma because 31% of the cohort in that study had mixed-acuity or chronic subdural haematoma.2 Therefore, the SHE score does not support an approach to limit treatment for older patients with acute subdural haematoma, with best available evidence suggesting the opposite.3–5 Third, Beucler presumes a benefit of primary decompressive craniectomy over craniotomy to account for the absence of benefit of acute surgery. Since treatment allocation was based on neurosurgeon preference, the effect estimate is applicable to patients for whom the neurosurgeon would consider both treatment options.