When should I consider referring a patient with a subdural haematoma for neurosurgical evaluation?

Consider referring a patient with a subdural haematoma for neurosurgical evaluation if any of the following are present:

• New and surgically significant abnormalities on imaging, as defined by local neurosurgical centres and agreed referral procedures.
• Persisting coma with a Glasgow Coma Scale (GCS) score of 8 or less after initial resuscitation.
• Unexplained confusion that persists for more than 4 hours.
• Deterioration in GCS score after admission, especially worsening motor response.
• Progressive focal neurological signs.
• A seizure without full recovery.
• A definite or suspected penetrating head injury.
• A cerebrospinal fluid leak.

These criteria indicate the need to discuss the patient's care plan with a neurosurgeon urgently to determine the need for transfer or intervention.