For a focal hematoma with mass effect, which surgical intervention is indicated?

• A. Burr hole only without evacuation
• B. Craniotomy and evacuation of the hematoma
• C. Observation alone
• D. Medical therapy

Answer: (B)

When a focal hematoma is producing mass effect, the priority is to rapidly relieve the pressure by removing the clot and controlling bleeding. A craniotomy with evacuation provides a wide surgical window to directly access the hematoma, evacuate it completely, achieve hemostasis, and decompress the brain. This direct decompression is essential to reduce intracranial pressure and prevent further brain injury or herniation.

Removing the clot through a burr hole without full evacuation would leave residual mass and likely fail to relieve the pressure, so it’s not sufficient when mass effect is present. Observation or medical therapy cannot address the physical compression from the hematoma, making them inappropriate in this scenario.