November 05, 2014
Evacuation of an acute subdural hematoma is one of the most fundamental procedures in neurological surgery. Let's discuss this procedure. This is a 62 year old female on Coumadin who was found obtunded after a suspected fall. Her CT scan demonstrated evidence of an acute subdural hematoma mixed with a chronic versus subacute, subdural hematoma, leading to a significant mass effect and midline shift. Emergency craniotomy is indicated. She underwent a left front temporal craniotomy. You can see the generous scalp incision. Completion of the leg of the incision close to the root of zygoma is evident. The temporalis muscle is reflected anteriorly and inferiorly. A burr hole is placed just inferior to the superior temporal line posteriorly. Placement of the burr hole here will avoid the bone loss in the area of the keyhole where traditionally this burr hole is placed. This is more cosmetically appealing. A left sided front temporal craniotomy is completed since brain swelling is not suspected. A relatively small craniotomy is quite effective to remove the acute subdural hematoma. The bone flap is elevated. The pterion is not drilled. The sphenoid wing is left intact. The dura is open in a curvilinear fashion and the hematoma is evacuated using suction. A number four pen felt the sector. If brain swelling is suspected because of history of severe closed head injury, a larger craniotomy would be appropriate so that a generous craniectomy can be performed, if necessary. Here is removal of the bone and opening of the dura leading to evacuation of the hematoma using suction. The next most important maneuver is evacuation of the clot underneath the edges of the craniotomy using ample amount of suction and irrigation fluid. I carefully inspect the edges of the craniotomy and remove the hematoma. I avoid the part of the hematoma close to the superior sagittal sinus and parasagittal draining veins as blind inspection of this area can lead to bleeding that is not easily controllable. Next, as you can see, the edges of the craniotomy are getting inspected. The hematoma along the floor of the middle fossa is being evacuated. The blood is in different stages of development based on the findings on preoperative CT scan. The closure is standard. A subdural drain was installed. The bone flap was replaced using miniplates and the closure was conducted in standard fashion. Post operative CT scan demonstrates adequate evacuation of the hematoma without any complicating features. Thank you.
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