May 13, 2014
Let's discuss evacuation of subacute subdural hematomas via burr holes. This is a 45 year-old male who was on anticoagulants with a remote history of minor trauma who presented with gait ataxia. CT scan demonstrated a right frontal subacute hematoma in the subdural space. The hematoma is isodense to the rest of the brain. He underwent burr hole evacuation of the hematoma. I believe chronic and subacute hematomas can be effectively drained via two burr holes. However, the hematomas that are mostly acute will require small craniotomy for their evacuation. Let's go ahead and review patient positioning. You can see the use of a Mayfield horseshoe or a mastoid headrest so that the posterior frontal and parietal region are accessible for placement of burr holes. The midline is marked, the head slightly turned, and two incisions are marked for this patient as anteriorly as possible, so that the hematoma can be drained via two burr holes. Using a single burr hole alone, specially for a subacute hematoma can be problematic and can lead to subtotal removal of the hematoma. The head is also situated, as you can see here. Draping is complete, adequate space for placement of the drain is created following completion of the incisions. These small self-retaining retractors or mastoid retractors are used. I used a perforator for completion of the burr hole. After the two burr holes are completed, the dura is apparent. The dura is opened in cruciate fashion and the subdural hematoma is evacuated. I used ample amount of irrigation via both burr holes to irrigate through one burr hole and evacuate the hematoma via the other burr hole. Multiple rounds of irrigation are used to adequately evacuate the hematoma effectively. After the irrigant is clear, a drain is placed through the anterior burr hole, subdurally toward the posterior burr hole. Obviously, any injury to the pia is avoided. This drain is passed and tunneled subcutaneously. Here's placement of the drain, tunneling of the drain, as well. Here's the closure with a drain tunneled out and stapled to the scalp so that displacement of the drain is minimized. A delayed CT scan of the patient demonstrates almost complete evacuation of the hematoma without any complicating features. Thank you.
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