Great job! The patient had a very symptomatic acute SDH with a smaller acute-on-chronic SDH on the contralateral side. Operative intervention was warranted, and was wisely not deferred in favor of things like hyperosmolar therapy.
The best available evidence specifically randomized patients to usual care (e.g. surgical evacuation) vs. usual care + adjunctive MMA embolization. There are certainly some patients who may not be surgical candidates (e.g. pancytopenic patients on chemotherapy, thrombocytopenic patients with hepatic dysfunction), so it's intriguing whether these patients could also benefit from MMA embolization, albeit in a primary, non-adjunctive fashion. This is currently unknown, though there are some RCTs that are actively enrolling that aim to help answer this question.
We generally love giving hyperosmolar therapy. It's great for intracranial hypertension, but not always so great for herniation. It helps to know the patient's baseline physiology; if they already have atrophy (think of your older patients), then hyperosmolar therapy might just shrink the parenchyma slightly, giving the hematoma more chance to expand and cause more trouble. If cerebral edema is a major contributor, it's fine to use hyperosmolar therapy as a temporizing maneuver, but don't forget to consider the definitive management option of surgery, if available.
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