6. Indication for evacuation of intracranial
hematomas
• aEDH
• aSDH
• Intraparenchymal Hemorrhage and contusion
• Posterior Fossa Mass Lesions/Hemorrhages
• Depressed Skull Fractures
Guideline for the surgical management of Traumatic brain injury 2006
7. aEDH
• Indications for Surgery
• EDH larger than 30 cc : operatively
• EDH smaller than 30 cc, less than 15 mm thick, and with less than a 5-mm
midline shift in patients with a GCS score lower than 8 without focal deficit
can be managed : : nonoperatively
• Timing
• Patients in coma with aEDH (GCS score <9) and anisocoria
undergo surgical evacuation as soon as possible.
• Important caveat
• EDH in the middle fossa/inferotemporal lobe should have a lower threshold
for surgery
8. aSDH
• Indications for Surgery
• aSDH with thickness greater than 10 mm or a midline shift of greater than 5
mm on CT : operatively
• All patients in coma with aSDH (GCS score <9) : ICP monitoring
• A comatose patient (GCS score <9) with an aSDH smaller than 10 mm and a
midline shift of less than 5 mm should undergo surgical evacuation of the
lesion if
• GCS score drop > 2
• asymmetric or fixed and dilated pupils
• ICP exceeds 20 mm Hg.
9. Intraparenchymal Hemorrhage and contusion
• Indication for surgery
• progressive neurological deterioration referable to the lesion,medically
refractory intracranial hypertension, signs of a mass effect on CT : operatively
• GCS 6-8 + frontal or temporal contusions larger than 20 cc with a midline shift
of at least 5 mm or cisternal compression on CT : operatively
• Volume larger than 50 cc : operatively
• not show evidence of neurological compromise, have controlled ICP, and do
not exhibit significant signs of a mass effect on CT : non-operatively + serial
imaging
• Craniotomy
10. Posterior Fossa Mass Lesions/Hemorrhages
• Mass effect on CT brain or neurological dysfunction : Operatively
• distortion, dislocation, or obliteration of the fourth ventricle
• compression or loss of visualization of the basal cisterns
• the presence of obstructive hydrocephalus
• Suboccipital craniectomy
11. Depressed Skull Fractures
• Open (compound) cranial fractures depressed greater than the
thickness of the cranium : operatively
• Nonoperative management
• No clinical or radiographic evidence of dural penetration
• No significant ICH
• No depression greater than 1 cm
• No frontal sinus involvement
• No gross cosmetic deformity
• No wound infection
• No pneumocephalus
• No gross wound contamination
12. Evaluation of Relevant Findings on CT
• Posttraumatic Mass Volume Measurement in Patients with Traumatic
Brain Injury
• Radiographic Correlates of Outcome
13. Posttraumatic Mass Volume Measurement in
Patients with Traumatic Brain Injury
• ABC method
• A largest diameter in slice 1
• B orthogonal to A
• C
• Compare each 10-mm slice with slice 1.
• > 75% of slice 1, count that slice as 1.
• 25% to 75%, count the slice as 0.5.
• < 25%, count the slice as zero (do not count the slice).
• Add these totals to get “C.”
• ABC/2
14. Radiographic Correlates of Outcome
• Standard
• 5-mm slices from the foramen magnum to the sella
• 10-mm slices above the sella, parallel to the orbitomeatal line
• Compressed or absent basal cisterns
• Midline shift (MLS) at the foramen of Monro
• MLS = (A/2) − B.
• Traumatic subarachnoid hemorrhage (tSAH)
15. Preoperative Preparation
• mean arterial pressure greater than 70 mm Hg (>90 mm Hg until
cerebral perfusion pressure [CPP] can be measured)
• CPP higher than 60 mm Hg
• euthermia, eucapnia
• oxygen saturation greater than 93%
• Pao2 of 95 to 100 mm Hg
• ICP higher than 20 mm Hg
• serum sodium concentration of 135 to 145 mEq
• Intubate protect airway
16. Preoperative Preparation
• Prophylactic hyperventilation or the use of mannitol is no longer
recommended
• Unless the patient exhibits focal neurological signs (contralateral
weakness, ipsilateral anisocoria or “blown pupils,” decerebrate or
decorticate posturing)
• hyperventilated to a Paco2 of 30 to 32 mm Hg
• given 1 g/kg of mannitol immediately
17. Preoperative Preparation
• Anticoagulant and antiplatelet drugs
• chronic alcoholism and chronic aspirin ingestion
• Recombinant factor VIIa (rFVIIa)
• induce hemostasis within 10 minutes
• decrease hematoma expansion in patients with hypertensive
hemorrhage and trauma
• Expensive
• 20 – 40 mg of rFVIIa
• 5 to 10 mg of vitamin K intravenously, platelets FFP
19. 4 cm from midline
2 cm in front of coronal suture
10 cm fron superior orbital rim
7-10 cm from surface of skull
20. Exploratory bur hole
• CT unavaible
• Bur hole on
• ipsilateral to a dilated pupil
• contralateral to the most abnormal motor response
• ipsilateral to a skull fracture
21.
22. General consideration for supratentorial
hematoma
• Rationale for Use of a Large Craniotomy
• Craniotomy Technique
23. Rationale for Use of a Large Craniotomy
• Require debridement
• Frontal pole
• Temporal pole
• Inferior part of frontal lobe
• Craniotomy should no closure more than 1.5-2 cm from midline :
avoid saggital sinus and parasaggital granulation
26. EDH
• Associated linear skull fracture
• Bleeding from
• anterior or posterior divisions of the middle meningeal artery
• middle meningeal vein, the diploic veins, or the venous sinuses
• Usually clot
• Temporal location should have lower threshold for surgery
27. Operative technique
• Frontotemporoparietal or a large pterional craniotomy
• Slash incision and can extend to trauma flap
• Epicenter of the EDH to provide complete exposure of the hematoma
such that the margins are approximately 5 mm less than the diameter
of the EDH : allow optimal dural “hitching”
• Initial bur hole is placed over the thickest part of the clot to reduce
ICP
• Intramural reperfusion hematoma : develop rapidly under a removed
extradural hematoma
28. Operative technique
• Incision
• Raney clip
• Strip periosteum
• Craniotomy : two to four bur hole
• Dural tack-up suture : no more than 2.5 cm
• Central dural tack-up suture
• Remove blood clot and stop bleeding source
• Replace bone flap
• Vacuum drain under galeal layer
29. aSDH
• Associated intracranial lesion : contusions, hematomas, or cortical
lacerations
• Important and potentially lethal complication of anticoagulant
therapy.
30. Operative technique
• Large frontotemporoparietal craniotomy
• Dura opening
• Remove clot : SDH, intracerebral
• Bleeding point
• Cortical surface : bipolar
• Bridging vein : bipolar
• Sinus wall : Gelfoam,Surgicel or Aveitene and gentle temponade with
cottonoid pad
31. Operative technique
• If diffuse oozing is persistent
• PT, PTT, platelet count, and INR
• Five to 10 units of FFP, rFVIIa, or up to 5 to 10 packs of platelet
concentrate
• Dural peripheral tack-up sutures
• Duraplasty
32. Intraparenchymal hemorrhage and contusion
• Repeat CT brain daily over the first 3 day
• Delayed traumatic intracerebral hemorrhage : develop of radiographic
injury in 24-72 hr
• Early identification and treatment, improve outcome
• Bifrontal craniotomy or bifrontal decompressive craniectomy
33. Operative technique
Incision : behind hairline,starting at zygoma
Burr hole temporal and frontal region
midline low frontal burr hole :
10 mm above nasion
Bilateral dura opening with the flap base to ward the saggital sinus
35. Posterior fossa hematoma
• Silent and slow
• Obstructive hydrocephalus and brain stem compression
• Most common : EDH
• Seizure prophylaxis ; coexistent supratentorial injury
36. Operative technique
flexed anteriorly at the occipitocervical junction
bone removal over the venous sinuses
performed last
decompress
upper : edge of transverse sinus
inferior : foramen magnum
37. Decompressive craniectomy
• always be extensive, approximately 15-cm craniectomy(AP diameter)
• frontotemporoparietal craniectomy or bifrontal craniectomy
• the dura must be opened widely as well
• intractable ICP develops after a
craniotomy has already been
performed : T-off incision
38. Depressed skull fracture
• Indication for surgery
• the depth of the depressed fragments of the fracture is equal to or
greater than the width of the surrounding bone
• the fracture occurs over cosmetic areas such as the forehead
• the fracture is of a compound variety
• there is a significant underlying ICH that requires surgery.
39. Linear incision or lazy S incision
Burr hole at the edge of fracture
not apply any downward pressure on the
40. Miniplates
Dura graft
When the wound is heavily contaminated or
more than 24 hours old : delayed
cranioplasty 1 to 2 months later
41. Compound frontal air sinus injury
• Nondepressed fractures through only the posterior wall of the frontal
sinus : do not surgical repair
• When the force is significant enough to penetrate the anterior and
posterior tables : high rate infection sepsis
42. bicoronal craniotomy
Incision 15 mm behind hairline
holes over the sagittal sinus in the midline
sinus mucosa removed : prevent mucocele
coronal flap is elevated to the
supraorbital rim and the zygomatic arches
vascularized galeal flap based
ostia are occluded with a muscle plug
fractures of the floor of the frontal fossa
43.
44. Depressed skull fracture over a venous sinus
• Occlusion of major sinus raise ICP with deteriorating neurological
status : urgent fracture elevation
• Transverse sinus : drainage of supratentorial and infratentorial,
significant asymmetry(right side dominant)
• Preoperative angiography or MRA
• Measuring ICP during occlusion,if pressure more than 20 mmHg :
mannitol, hyperventilation
45. Most important Head above heart
Right atrial catheter
Esophageal stethtoscope
47. Chronic subdural hematoma
• 3 wks or more after injury
• Symptom and sign are variable and non-specific : headaches,decline
in motor function, motor deficit
• Coagulpathy and anticoagulant therapy are accelerate these symptom
• Indication : > 1 cm. of maximum thickness or mass effect
• Management
• Bur hole with drainage
• Twist drill drainage
• Craniotomy
• Shunting
48. Cranioplasty
• Indication : after decompressive craniectomy for raised ICP
• 6-8 wk after procedure
• Hocky helmet before cranioplasty
• Autulogous bone flap
• Sterile in -70 C freezer
• Patient’s own abdominal subcutaneous tissue : complication bone resorption
• Methy methacrylate and titanium mesh
49. Mannitol with hyperventilate
Stop bleeding for prevent
postcranioplasty hematoma
Subgaleal plane :
NSS to infiltrating
Piece of wet gauze
Cold saline
Material in plastic bag
51. Complication
• Bleeding
• Recurrent hematoma
• FFP, platelet conc,rFVII
• Final hemostasis should be achieved at PaCO2 35-40 mmHg and Valsalva
maneuver
• Profuse bleeding from laceration of the carotid artery from base of skull :
angiography and intra-arterial balloon occlusion
• Coagulopathy associated with TBI
• Risk factor for DIC
• Brain rich in thromboplasmin(tissue factor)
52. Complication
• Acute/intraoperative brain swelling
• MAP at 70-80 mmHg
• Reassess ET tube, ABG, Hyperventilation
• Bleeding from ipsilateral or contralateral hematoma : intraoperative US
• Hypothermia or pentobarbital
• Etomidate or propofol
• Postcraniotomy hematoma
• Skull base fracture and CSF leak