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

Subdural hematoma (SDH) is a type of intracranial bleeding that occurs between the dura and the arachnoid membrane surrounding the brain. The presented video is a step-by-step demonstration of a hematoma evacuation by craniotomy performed on an elderly female patient with an acute-on-chronic SDH, presumably resulting from recurrent head injuries sustained from falls. The patient presented with altered mental status with a GCS score of 8.

<h4>CHAPTER 1</h4>

<p>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.</p>

<h4>CHAPTER 2</h4>

<p>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.</p>

<h4>CHAPTER 3</h4>

<p>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.</p>

<h4>CHAPTER 4</h4>

<p>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.</p>

<h4>CHAPTER 5</h4>

<p>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.</p>

<h4>CHAPTER 6</h4>

<p>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.</p>

<h4>CHAPTER 7</h4>

<p>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.</p>

<h4>CHAPTER 8</h4>

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

<h4>CHAPTER 9</h4>

<p>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?</p>

<h4>CHAPTER 10</h4>

<p>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.</p>


Watch this full-length, narrated surgical video of an acute subdural hematoma evacuation by craniotomy. 

DOI
Publication Date	2024/04/26
Article ID	140
Production ID	0140
Volume	2024
Issue	140
https://doi.org/10.24296/jomi/140

Acute Subdural Hematoma Evacuation

Procedure Outline

Table of Contents