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  • 1. Introduction
  • 2. Positioning and Draping
  • 3. Skin Incision
  • 4. Burr Hole and Craniotomy
  • 5. Dural Opening
  • 6. Hematoma Evacuation
  • 7. Dural Closure
  • 8. Bone Flap Reimplantation
  • 9. Closure
  • 10. Post-op Remarks
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Acute Subdural Hematoma Evacuation


Vincent Prinz, MD; Marcus Czabanka, MD
Charite Hospital Berlin



Hello my name is Vincent Prinz, and right now we're planning to do an evacuation of an acute subdural hematoma. We are having an elderly lady, which had trauma and actually showed up with reduced consciousness and Glasgow Coma Scale of eight. You can very nicely see the hyperintense - hyperdensity, which shows that there’s acute blood subdurally. In fact, if you take a closer look, you can see that most probably the lady was suffering from a chronic subdural hematoma, which then is shown in rather gray to dark stages, and the acute content of the hematoma is depicted here as a hyperdensity in white, so she probably might have had some space, let's say, under the dura - so the hematoma, which develop after the trauma acutely now could rather get in there very acutely. So, this is what we are - basically can see from the pictures. And furthermore, we can see that she has a little bit of a midline shift here, and the right lateral ventricle seems to be a little bit compressed.


One of the major points for positioning the patient to perform the surgery is that the head is flipped or twisted 90 degrees. So we have a flat - what do you say - a flat plane, and the highest point - the highest point of the head will be the hold - the - the place where we do the hole. So we can at the end fill it up very closely, and there will hopefully no air be remaining within the head. Furthermore, especially in elderly patients, where the neck can be rather stiff due to degenerative circumstances, you - most of the time you need to - need to - to have a - to have a pillow under the shoulder so you can also rotate most of the body to the other side where you want the head to be. And furthermore, what you also want to avoid is that you flip the head too much so that the uvala veins will - will be compressed, which could lead to a higher intracranial pressure and furthermore to higher blood backflow, so to say. So it would be harder - would be hard to have the bleeding under control during surgery and also afterwards.


Okay, the first step of course is Schnidt. So we do the skin incision. Then we just have a little look. Control superficial bleeding of the skin. And then we do not need to control all of the bleeding, but then quickly get a retractor in, which by itself, due to - which by itself, due to its compressive action, will help to control the bleeding. With the monopolar forceps, we then expose the scalp. Then we take a respiratorium to completely expose the skull and move the peri-os a little bit to the side. With the retractor. Not necessary - still some minor bleeding. Bipolar. Yeah, of course. And now we will be ready to do the first burr hole.


So the drill has a special mechanism that when the counter-pressure, so to say, stops, it would toward - it will by itself stop drilling, so we don't have the risk to fall into the head, so to say. Of course, you always need to maintain the pressure - that was it already. We need to clean all the bone pieces aside to avoid that they spread everywhere and may cause infection, you know? So now we elevate it from the dura, and luckily we did not injure the dura. B-pole.


So the next step then is to open the dura. This is the dura, here. We can do it this way, okay. So you put a tiny needle in a superficial way through the dura - leave enough space to the rim, so in the end, we can suture it back again. And here you can already see the hematoma below it. Then we go in with the scissors. Always try to point the tip so you do not injure anything. And here we have the hematoma. So here, where my suction is, is the rim of the dura. Here is the dura we just removed, and here you can see the hematoma.


There seems to be a tiny little skin above it. Here we go. And here comes the hematoma. Suction. So as you can see that was a tiny skin above the hematoma, which we now take off. So the - this is all hematoma. And here you can see the brain below it. So you try - basically, you try to suck the hematoma away. And so the suction right now is right strong - quite strong. Therefore - therefore, we have to be very careful not to - not to - to touch the brain using the suction, but to just be - have the suction 90 degrees to it. And now you can already see how the brain starts pulsating again. Sorry, I need to move it over here. B-pole. Okay. Done.


So I do first of all just for orientation - one closure in the middle... B-pole. So the stitches - was it... So it's a 4-0 suture. We will see the dura, again. So we got the sutures.


Oh this - okay. So that's it - it's tight, and it’s re-fixed. Take off the pins.


So... Okay. So at first glance - now the wound doesn't look that nice, but after removal of the stitches, it will be fine. Okay?


So taken together, we had an elderly lady, which suffered from an acute subdural hematoma - most probably based on a chronic hematoma, which she had developed before. We did a little burr hole and then a little craniotomy, and doing this, we could remove the hematoma and decompress the brain. Therefore, you could see in the surgery that when the pressure from the hematoma was removed, the brain, by itself, started pulsating much better than before, again, and also, the the level of the brain lifted directly, which also helps us to stop the bleeding. Of course, you need lot of - you need a lot of irrigation to get the whole blood out and to finally stop - stop also the bleeding and to help to take out all the hematoma components in there. Of course, most of the time you need the suction and step-by-step remove the hematoma. And then finally, seal the dura up, put the bone back again in, and, of course, close the skin.