Operative Planning

• Review imaging: computed tomography
  
• Factors considered in patient selection include: clot location, neurologic condition, prognosis, age and medical condition, underlying pathology, and patient’s and family’s wishes
  
• Cerebellar hemorrhages are considered a neurosurgical emergency

Anesthetic Issues

• Arterial line blood pressure monitoring: keep cerebral perfusion pressure as close to 70 mm Hg as possible and avoid extremes of hypo- and hypertension
  
• Intravenous antibiotic prophylaxis
  
• Mannitol for brain relaxation
  
• Phenytoin load if not already begun, except for cerebellar hemorrhages

Positioning

• Patient supine with head held either in Mayfield three-point fixation or on foam doughnut
  
• Head is turned to side opposite lesion, with neck flexed and extended and head elevated to crate a vertical trajectory to the lesion
  
• Ipsilateral shoulder roll
  
• For occipital or cerebellar hematomas, patient can be positioned prone with rigid head fixation

Incision

• Depending on location and size of craniotomy, a linear or U-shaped incision based laterally can be used
  
• We favor midline suboccipital craniotomy or craniectomy is used for evacuation of cerebellar hematomas because of improved healing (unless the lesion is extremely lateral in location)

• Size and location of the craniotomy are guided by location of the clot
  
• A single burr hole is usually sufficient
  
• The medial extent of bone flap should be at least 2 cm away from the midline to avoid the superior sagittal sinus and arachnoid granulations
  
• Bone flap is elevated with Penfield no. 3 and flap elevator
  
• Holes for dural tenting sutures, central tenter, and microplate fixation of bone flap are drilled, avoiding the medial edge near sagittal sinus
  
• Craniotomy edges are lined with strips of Surgicel and 4–0 silk dural tenting sutures are placed

Dural Opening

• Cruciate or U-shaped dural opening
  
• Transcortical approach to the clot is begun with pial cauterization using irrigating cautery, sharp division with pinch microscissors, and gentle suction

Clot Evacuation

• Large suction tips are used to aspirate clot
  
• Hemostasis is achieved with a combination of the following: irrigating bipolar cautery, Avitene, hydrogen peroxide soaked cotton balls, Gelfoam, Surgicel, and FloSeal

Closure

• Warm irrigation
  
• Surgical bed lined with Surgicel and/or Avitene
  
• Dural closure with 4–0 silk sutures and a central tenting suture placed
  
• The bone flap secured with microplates and screws
  
• The galea closed with inverted, interrupted 3–0 Vicryl sutures
  
• Skin closed with staples; a compressive head wrap is applied

• Intensive care unit care with strict blood pressure control
  
• Height of bed 30 degrees
  
• Monitor anticonvulsant levels