CRANIOTOMY IN

PATIENT WITH
SUBDURAL
HEMMORAGE
MAGNO | ROMERO | SANTOS
 OVERVIEW OF
SUBDURAL
HAEMATOMA

• A subdural haematoma is a serious condition

where blood collects between the skull and the
surface of the brain. It's usually caused by a head
injury.
 a headache that keeps getting worse

feeling and being sick

Symptoms of a confusion

subdural
haematoma personality changes, such as being unusually aggressive or having rapid mood swings

can include: feeling drowsy

loss of consciousness

The symptoms can develop soon after a severe head injury (acute subdural haematoma),
or very occasionally a few days or weeks after a more minor head injury (subacute or
chronic subdural haematoma).
What causes subdural haematomas?

Blood escapes from the blood

A subdural haematoma occurs Head injuries that cause subdural
vessel, leading to the formation
when a blood vessel in the space haematomas are often severe,
of a blood clot (haematoma) that
between the skull and the brain such as those from a car crash,
places pressure on the brain and
(the subdural space) is damaged. fall or violent assault.
damages it.

A minor head injury is more

likely to lead to a subdural
But minor bumps to the head can
haematoma if you're over 60,
also lead to a subdural
taking blood-thinning medication
haematoma in a few cases.
such as warfarin, or have a
history of alcohol misuse.
 Subdural haematomas usually need to be treated with
surgery as soon as possible.
The 2 most widely used surgical techniques for
subdural haematomas are:
How subdural • Craniotomy – a section of the skull is temporarily
removed so the surgeon can access and remove the
haematomas are haematoma

treated? • Burr holes – a small hole is drilled into the skull

and a tube is inserted through the hole to help drain
the haematoma

In a few cases, very small subdural haematomas may

be carefully monitored first to see if they heal without
having an operation.
 • Craniotomy is a surgery to cut a bony opening in the
skull. A section of the skull, called a bone flap, is
removed to access the brain underneath. A craniotomy
may be small or large depending on the problem. It
CRANIOTOMY may be performed to treat brain tumors, hematomas
(blood clots), aneurysms or AVMs, traumatic head
injury, foreign objects (bullets), swelling of the brain,
or infection. The bone flap is usually replaced at the
end of the procedure with tiny plates and screws.
What is a
craniotomy?

• Craniotomies are named according to the area

of skull (cranium) to be removed. After the
surgeon repairs the problem, the bone flap is then
replaced or covered with plates and screws. If
the bone flap is not replaced, the procedure is
called a craniectomy.
Who performs the
procedure?

• A craniotomy is performed by a neurosurgeon; some

have additional training in skull base surgery. A
neurosurgeon may work with a team of head-and-
neck, otologic, oculoplastic and reconstructive
surgeons. Ask your neurosurgeon about their
training, especially if your case is complex.
What happens before surgery?
The surgeon will explain the procedure, its risks and benefits, and you will have time to ask questions. Consent forms are signed and paperwork
completed to inform the surgeon about your medical history (e.g., allergies, medicines, anesthesia reactions, previous surgeries). Presurgical
tests (e.g., blood test, electrocardiogram, chest X-ray) may need to be done several days before surgery. Consult your primary care physician
about stopping certain medications and ensure you are cleared for surgery.

Stop taking all non-steroidal anti-inflammatory medicines (ibuprofen, naproxen, etc.) and blood thinners (Coumadin, aspirin, Plavix, etc.) 7
days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.

If image-guided surgery is planned, an MRI will be scheduled before surgery. Fiducials (small markers) may be placed on your forehead and
behind the ears. The markers help align the preoperative MRI to the image guidance system. The fiducials must stay in place and cannot be
moved or removed prior to surgery to ensure the accuracy of the scan.

You may be asked to wash your skin and hair with Hibiclens (CHG) or Dial soap before surgery. It kills bacteria and reduces surgical site
infections. (Avoid getting CHG in eyes, ears, nose or genital areas.)
 Obtain informed consent

Provide information to the patient or significant other about the procedure

Skin preparation

PRE- Identify prescription drugs, over-the-counter medications, and herbal supplements taken by the
patient that may result in drug interactions affecting the surgical outcome.
OPERATIVE
Determine the patient’s psychologic status in order to reinforce the use of coping strategies
during the surgical experience.

Document the results of all preoperative laboratory and diagnostic tests in the patient’s record and communicate this
information to appropriate health care providers.

As a preparation for the procedure, general anesthesia is administered through an IV placed in the arm, before the
surgery to put the patient to sleep completely. However, if the patient is undergoing an awake craniotomy, general
anesthesia is given, but the patient will be awake for a part of the procedure. In case of stereotaxy, local anesthesia is
administered only in the area of operation.
What happens during
surgery?

Depending on the underlying problem being treated, the surgery

can take 3 to 5 hours or longer.
Step 1: prepare the
patient
• You will lie on the operating table and be given general
anesthesia. Once you are asleep, your head is placed in a
3-pin skull fixation device that attaches to the table and
holds your head absolutely still during surgery. A brain-
relaxing drug called mannitol may be given.
• If image-guidance is used, your head will be registered
with the infrared cameras to correlate the “real patient”
to the 3D computer model created from your MRI scans.
The system functions as a GPS to help plan the
craniotomy and locate the lesion. Instruments are
detected by the cameras and displayed on the computer
model.
 • The incision area of the scalp is prepped with an
Step 2: make a skin antiseptic. Skin incisions are usually made behind
the hairline. A hair sparing technique is used, where

incision only a 1/4-inch wide area along the proposed

incision is shaved. Sometimes the entire incision
area may be shaved.
 Step 3: perform a
craniotomy, open the
skull

• The neurosurgeon carefully makes an incision in the

skin above the brain hemorrhage. Small burr holes are
drilled to allow the insertion of microsurgical saws to
create a temporary opening in the bone. The bone flap
is removed, creating a small window, and set aside to
be attached later.
Step 4: expose the
brain
• Through this small window, the dura is carefully
incised to provide an entrance to the hematoma.
Burr hole surgery may also be used to divert
excess fluid away from the brain, which can
decrease cerebral pressure and avert possible
brain damage.
• A special surgical device gently suctions the
excess blood, and if necessary, any additional
bleeding is cauterized.
 • Enclosed inside the bony skull, the brain cannot be
easily moved aside to access and repair problems.

Step 5: correct the

Neurosurgeons use a variety of very small instruments
to work deep inside the brain. These include long-
handled scissors, dissectors and drills, lasers, and
problem ultrasonic aspirators (uses a fine jet of water to break
up tumors and suction up the pieces). In some cases,
evoked potential monitoring is used to stimulate
specific cranial nerves while the response is
monitored in the brain. This is done to preserve
function of the nerve during surgery.
Step 6: close the
craniotomy

• Once the subdural hemorrhage has been cleared,

the dura is sutured, and the small piece of skull
reattached with surgical pins and screws. If
necessary, the reattachment of the skull piece
may be postponed, and a drain may be
temporarily located at the incision to prohibit
accumulations of fluids. The scalp skin is then
sutured closed.
CRANIOTOMY IN PATIENT WITH SUBDURAL HEMMORAGE
 • You are taken to the recovery room where vital signs are
monitored as you awake from anesthesia. You may have a sore
throat from the tube used to assist your breathing. After you
awaken, you’ll be moved to the intensive care unit (ICU) for
close monitoring. You are frequently asked to move your arms,

What happens after fingers, toes, and legs. A nurse will check your pupils with a
flashlight and ask questions, such as "What is your name?" You
may experience nausea and headache after surgery. Medication

surgery? can control these symptoms. Depending on the type of brain

surgery, steroid medication (to control brain swelling) and
anticonvulsant medication (to prevent seizures) may be given.
When your condition stabilizes, you’ll be transferred to a regular
room where you’ll begin to increase your activity level.

• The length of the hospital stay varies, from only 2–3 days or 2
weeks depending on the surgery and any complications. When
released from the hospital, you’ll be given discharge instructions.
Patient may experience:

Nausea: Post-operative nausea may be related to your pain medications. If possible, take the medication
with food. Eat small, frequent meals and avoid spicy or fried food.

Fatigue: It may take 6 weeks or more for your energy level to return to normal. You will probably feel very
fatigued for the first 2 weeks then notice a gradual increase in energy thereafter.

Constipation: This is a common problem after surgery due to anesthesia, inactivity, and prescription pain
medications. It is helpful to increase water, fresh fruits and vegetables, fiber and bran in your diet.

Side effects of steroid medications: You may be discharged from the hospital on a steroid medication
(dexamethasone) to decrease brain swelling
 POST - OPERATIVE

Keep the incision

Advise patient to get
clean. Craniotomy Watch the incision for
plenty of sleep to help
incisions are usually signs of infection or Control Pain.
their body recover
closed with sutures or complications.
faster
surgical staples.

Advised patient to take

Early ambulation as
No heavy weightlifting medications in time as
tolerated to reduce risk
or straining prescribed by their
of blood clots
health
 You may shower the day after surgery and wash your hair with mild baby shampoo.
Gently wash the incision area with soap and water every day. Don’t scrub or let the
water beat hard on your incision. Pat dry.

If Dermabond skin glue covers your incision, don’t rub or pick at the glue.

Incision Care Don’t submerge or soak the incision in a bath, pool or tub. Don’t apply
lotion/ointment on the incision, including hair styling products.

You may hear strange noises (popping, crackling, ringing) inside your head. This is
normal healing as air and fluid reabsorb.

Don’t color your hair for 6 weeks. If you cut your hair, use caution near the incision.
 Headaches are common after surgery. You may take
acetaminophen (Tylenol).

Take pain medicines as directed by your surgeon. Reduce the

amount and frequency as your pain subsides. If you don’t need
the pain medicine, don’t take it.

Narcotics can cause constipation. Drink lots of water and eat

Medications high-fiber foods. Stool softeners and laxatives can help move
the bowels. Colace, Senokot, Dulcolax and Miralax are over-
the-counter options.

Anti-seizure medicine may be prescribed. Some patients

develop side effects such as drowsiness, balance problems, or
rashes. Call the office if any of these occur.

Don’t take anti-inflammatory pain relievers (Advil, Aleve),

blood thinners, or supplements without surgeon’s approval.
 Get up and walk 5-10 minutes every
3-4 hours. Gradually increase walking
as you are able.

Swelling and bruising of the eye or

Activity face may occur. It will take several
weeks to go away.

Sleep with your head elevated and

apply ice 3-4 times per day for 15-20
minutes to help reduce pain and
swelling.
 Fever over 101.5º (unrelieved by Tylenol).

Signs of incision infection, such as spreading redness, separation, or colored

drainage.

Increased drowsiness, weakness of arms / legs, increased headaches, vomiting, or

severe neck pain that prevents lowering your chin to chest.
When to Call
New or worsening vision, speech or confusion.
Your Doctor?
Swelling at the incision with leaking of clear fluid from your ear or nose.

Swelling and tenderness in the calf of one leg.

Seizure
 • A follow-up appointment is made 10 to 14 days after
surgery. The recovery time varies from 1 to 4 weeks
depending on the underlying disease being treated and
Recovery your general health. Full recovery may take up to 8
weeks. Walking is a good way to begin increasing
your activity level. Do not overextend yourself,
especially if you are continuing treatment with
radiation or chemotherapy. Ask your surgeon when
you can expect to return to work.
 • No surgery is without risks. General complications of

What are the risks? any surgery include bleeding, infection, blood clots,
and reactions to anesthesia. Specific complications
related to a craniotomy may include stroke, seizures,
swelling of the brain, nerve damage, cerebrospinal
fluid leak, and loss of some mental functions.
THANK YOU!