Among patients with traumatic subdural hematoma (SDH) and poor neurological presentation, operative neurosurgery is associated with improved discharge outcomes. The retrospective cohort study, which used the American College of Surgeons Trauma Quality Programs Dataset, included 13,393 adults with traumatic SDH, midline shift >5 mm, and a Glasgow Coma Scale ≤8. After evaluating pupillary response, the researchers determined that patients with non-reactive pupils had the lowest likelihood of undergoing operative neurosurgery, at a rate of 34% compared with 50% for one or both pupils responding (P < .001). After adjusting for risk factors, operative neurosurgery was significantly associated with a favorable discharge, with an odds ratio of 1.93. A patient’s pupillary response significantly affected this association, with the probability of a favorable outcome associated with the surgery increasing from 3.7% to 11.8% for patients with non-reactive pupils. The researchers noted that operative neurosurgery had potential benefit for all age groups, although positive outcomes were much less likely for individuals older than aged 75 years.