Acute Subdural Hematoma Evacuation

CHAPTER 1

Hello my name is Vincent Prinz, andright now we're planning to do an evacuationof an acute subdural hematoma.We are having an elderly lady, which had traumaand actually showed up with reduced consciousnessand Glasgow Coma Scale of eight. You can very nicely seethe hyperintense - hyperdensity,which shows that there’s acuteblood subdurally.In fact, if you take a closer look, you can see thatmost probably the lady was suffering from achronic subdural hematoma, which then isshown in rather gray to dark stages,and the acute content of the hematomais depicted here as a hyperdensity in white,so she probablymight have had some space, let's say,under the dura - so the hematoma, which developafter the trauma acutely now could rather getin 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 bea little bit compressed.

CHAPTER 2

One of the major points for positioning the patientto perform the surgeryis 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 wherewe do the hole.So we can at the end fill it up veryclosely, and there will hopefully noair be remaining within the head.Furthermore, especially in elderly patients,where the neck can be rather stiff due todegenerativecircumstances, you - most of the time you need to -need to - to have a - to have a pillowunder the shoulder so you canalso rotate most of the body to the other sidewhere you want the head to be.And furthermore, what you also wantto avoid is that you flip the headtoo much so that the uvala veins will -will be compressed, which could leadto a higher intracranialpressure and furthermore to higher blood backflow,so to say. So it would beharder - would be hard to have the bleeding undercontrol during surgery and also afterwards.

CHAPTER 3

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 controlall of the bleeding, but thenquickly get aretractor in, which by itself,due to -which by itself, due to its compressiveaction,will help tocontrol the bleeding.With the monopolar forceps, we then expose the scalp.Then we takea respiratoriumto completely expose theskull 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.

CHAPTER 4

So the drill has a specialmechanism that when the counter-pressure,so to say, stops, it would toward - itwill by itself stop drilling, so we don't have the risk to fall intothe head, so to say.Of course, you always need to maintain the pressure -that was it already.We need to clean all thebone pieces aside to avoidthat 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.

CHAPTER 5

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 needlein a superficial way through the dura -leave enough space to the rim, so in theend, we cansuture it back again.And here you can already seethe hematoma below it.Then we go in with the scissors. Always try to point the tipso you do not injure anything.And here we have the hematoma.So here, where my suction is, is the rim of the dura. Here isthe dura we just removed,and here you can see the hematoma.

CHAPTER 6

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 atiny skin above the hematoma, whichwe 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 brainusing the suction,but to just be -have the suction 90 degrees to it.And now you can already see how the brainstarts pulsating again.Sorry, I need to move it over here.B-pole.Okay.Done.

CHAPTER 7

So I do first of alljust 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.

CHAPTER 8

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

CHAPTER 9

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?

CHAPTER 10

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 holeand then a little craniotomy,and doing this, we could remove the hematomaand decompress the brain. Therefore, you couldsee in the surgery that when thepressure from the hematoma was removed,the brain, by itself, started pulsatingmuch better than before, again, and also, thethe level of the brain lifted directly,which also helps us to stop the bleeding.Of course, you need lot of - you need a lot ofirrigation to get the whole blood out and tofinally stop - stop also thebleeding and to help to take out all thehematoma components in there. Of course,most of the time you need the suctionand step-by-step remove the hematoma.And then finally, seal the dura up, put thebone back again in, and, of course, close the skin.