Acute Subdural Hematoma Evacuation
- Positioning and Draping
- Skin Incision
- Burr Hole and Craniotomy
- Dura Opening
- Hematoma Evacuation
- Dura Closing
- Reimplantation Bone Flap
- Wound Closure
- Case Debrief
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Hello my name is Vincent Prinz, and right now we're planning to do a evacuation of acute subdural hematoma. We are having an elderly lady which had trauma and actually showed up with reduced consciousness by Glasgow Coma Scale of eight. You can very nicely see the hyper-intense - hyperdensity - which show us that there’s acute blood subdural. 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 showing in rather gray to - to dark and stages, and the acute content of the hematoma is depicted here as a hyper density 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 now get in the 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 - one of the major points for positioning the patient to perform the surgery is that the head is flipped or twisted 90 90 90 degrees, so we have a flat - what’s it's - 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 be no air remaining within the head. Furthermore, especially in elderly patients, where the neck can be rather stiff due to degenerative circumstances most of the time you need to - need to to - to have a pillow under the shoulder so you can also rotate most of the body to the other side where you want to - 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 ugala veins will - will be compressed which could lead to a higher inter-cranial 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 Schnitz. 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 mono-pilar forceps, we then expose the scalp. Then we take a respiratorium to completely expose the skull and move the parius a little bit to the side. With the retractor. Not necessary - still some minor bleeding people. 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 cont - counter pressure so to say stops it would - it will by itself stop drilling so we don't have to 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 - but they spread everywhere and may cause infection. So now we elevated from the dura, and luckily we did not injure the dura. People.
So the next step then is to open the dura. this is the dura here. We can do it this way - that’s 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. Shiv. Then we go in with the scissor - always try to point the tip, so you do not injure anything. And here we have the hematoma. So here where my section 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. 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 try to suck the hematoma away. And so the section right now is real strong - real strong. We have - we have to be very careful not to - not to touch the brain using the suction. To just be - just have the suction 90 degrees to it. So now you can already see how the brain starts pulsating again. So already - move over here. Okay - done - undoing it.
So I do first of all just the - for orientation. One closure in the middle and has a myo vital in one knot. So the stitches was it - so it's a 4-0 - 4-0 suture. We will see the dura again. So we got the sutures. Suck, suck.
Okay. So that's it - it's tight. 93 fixed. Take off the pins.
So give my - give my zip cortana. So at first glance - no, the wound doesn't look that nice, but after removal of the stitches, it will be fine. Okay. Smile, awesome.
So taken together we had an elderly lady who suffered from an acute subdural hematoma - most probably based on a chronic hematoma which she had developed before. We did a little - 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 level of the brain lifted directly, which also helps us to stop - to stop - 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 stopped - stopped 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 then step-by-step remove the hematoma. And then finally seize the dura up, put the bone back again in, and of course, close the skin. Thanks.
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