Craniotomy and Evacuation at Remote Island Hospital; Challenges and Way Ahead

We herein report the management of a case of acute-on-chronic subdural hematoma by emergency craniotomy at mid-zonal hospital with basic surgical facilities. The timely intervention has made significant difference in patient outcome. A 72-year-old male was on antiplatelet agents, presented with status epilepticus, and also had multiple comorbidities. We faced challenges of specialist consultation, medical evacuation of an intubated case, neurosurgery intensive care, and availability of blood products and intensivists at place like Andaman and Nicobar islands where connectivity remains a challenge. Casualty evacuation and transport of critical patients by air are a major exercise and are not possible in certain situations. Moreover, it is potentially detrimental to the life of a patient during air evacuation due to changes in the atmospheric pressure. In such adverse situations, aggressive surgical intervention at small centers can make significant difference in the outcome of patient.