1 Surgery for Epidural and Subdural Hematomas



10.1055/b-0035-121747

1 Surgery for Epidural and Subdural Hematomas

Shelly D. Timmons

Introduction


Rapid evacuation of extra-axial hematomas after trauma can be a life-saving intervention. While there is no absolute cutoff time after which patients fare worse, many studies have demonstrated better outcomes with earlier evacuation. Surgical planning must take into consideration the presence of other intracranial lesions and the patient′s clinical status. The presence of polytrauma, the patient′s hemodynamic status, 1 and the presence of coagulopathy must be considered and addressed while not delaying surgical intervention.



Indications




  • Surgical intervention is appropriate for epidural hematomas (EDH) with the following characteristics 2




    • Glasgow Coma Scale (GCS) score ≤ 8 and anisocoria → operating room as soon as possible



    • Hematoma volume ≥ 30 cm 3



    • Hematoma volume, 30 cm 3 but accompanied by:




      • Thickness ≥ 15 mm



      • Midline shift ≥ 5 mm



      • GCS ≤ 8



      • Focal motor deficit



    • Effaced cisterns



    • Deteriorating neurologic status



  • Surgical intervention is appropriate for subdural hematomas (SDH) with the following characteristics 3




    • Thickness ≥ 10 mm



    • Midline shift ≥ 5 mm



    • Thickness, 10 mm and midline shift, 5 mm but accompanied by:




      • Neurologic worsening by 2 or more points on the GCS



      • Asymmetric pupils



      • Fixed and dilated pupils



      • Intracranial pressure (ICP) ≥ 20 mm Hg



Preprocedure Considerations



Radiographic Imaging




  • Computed tomography (CT) is essential to evaluate for:




    • The presence and size of extra-axial hematoma



    • Degree of midline shift



    • Appearance of perimesencephalic cisterns



    • Presence of other space-occupying lesions



  • Preoperative imaging (Fig. 1.1).



Medications




  • Preoperative antibiotics: either a cephalosporin or vancomycin (if penicillin allergic) should be given.



  • The patient should be given seizure prophylaxis at earliest opportunity after arrival to the hospital. Evidence-based guidelines support the utilization of anticonvulsants for 7 days in patients following traumatic brain injury. 4



  • Fresh frozen plasma and/or other blood products/factors should be administered preoperatively and intraoperatively as needed to correct coagulopathy.



Operative Field Preparation




  • The head may be positioned on a doughnut or horseshoe head holder, rather than a three-pinion head holder, to facilitate more rapid progression to brain decompression.



  • The operative field should be prepared using an iodine-based sterile prep solution, provided the patient has no iodine allergies.



  • The use of chlorhexidine is controversial; product insert information bars the use for procedures exposing the cerebral meninges. In cases with known betadine or iodine allergies, chlorhexidine or alcohol prep can be used.



  • The incisions are marked and, after final sterile draping, infiltrated with 1% lidocaine with epinephrine 1:100,000.

Fig. 1.1a–d CT scan is the modality most commonly utilized in the perioperative setting. (a) Epidural hematomas demonstrate a characteristic convex shape (due to adherence of the dura at the suture lines) and are typically accompanied by a (b) fracture (arrow). (c) Subdural hematomas by contrast, are not bound by sutures and assume a crescentic appearance, layering over the convexity. (d) A small subdural hematoma may be accompanied by disproportionate mass effect and midline shift.


Operative Procedure



Positioning (Fig. 1.2a, b)

Figure Fig. 1.2 Procedural Steps (a, b) The head is turned so as to expose the operative hemicranium. The patient whose neck has not yet been cleared can be positioned in the cervical collar by placing a bolster under the ipsilateral shoulder and the ipsilateral arm across the chest. Pressure points should be padded appropriately. The head may be placed on a foam or gel doughnut to expedite positioning. Pearls • Discuss positioning with the anesthesiology team. The endotracheal tube (ETT) should exit the contralateral side of the mouth if placed orally, and should be secured in place using tape, ETT collar, etc. The eyes should be protected from corneal abrasion by placing ointment under each lid and taping the lids shut. • Allowance for central venous catheters, peripheral intravenous catheters, and arterial lines should be made, with these positioned toward the anesthesiology team if possible. Foley catheters should always be placed and should be accessible to the anesthesia team. • Pin fixation may also be used, but positioning on a doughnut or horseshoe head holder may expedite decompression of the brain. • The head should be positioned just at or slightly overhanging the end of the table and the sterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation by gravity. Final draping should exclude the anesthesia setup, using a vertical drape. • An exit site for a subgaleal drain should be included in the area exposed by the sterile draping. • Reverse Trendelenburg positioning may be used to provide elevation of the head to help reduce cerebral edema.


Skin Incision (Fig. 1.3)

Figure Fig. 1.3 Procedural Steps The skin incision should be planned to create a craniotomy sufficient to access the entire hematoma. The question mark or reverse question mark incision (illustrated here) is used commonly to access large traumatic extra-axial hematomas. Pearls • Other skin incisions may be utilized to evacuate smaller hematomas. However, before committing to a more limited exposure, consideration should be given to the degree of brain swelling anticipated. • When using a question mark incision, care should be taken not to place the incision too close to the pinna of the ear. A margin of at least 1 cm should be used. Likewise, the vertical limb of the incision should be placed at least 1 cm anterior to the tragus. The scalp may be elevated off of the underlying bone and retracted out of the way. • Scalp clips may be applied to the scalp edges to aid in hemostasis. • Prior to opening the scalp over the temporalis muscle, an instrument may be passed over the muscle fascia and the skin divided down to the level of the instrument with a scalpel. The temporalis may then be divided in parallel with the incision using Bovie cautery. • Branches of the superficial and middle temporal arteries may be encountered and may be ligated and divided sharply, or cauterized with the bipolar cautery.

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Jun 13, 2020 | Posted by in NEUROSURGERY | Comments Off on 1 Surgery for Epidural and Subdural Hematomas

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