SURGICAL MANAGEMENT OF ACUTE SUBDURAL HEMATOMAS A. J. M. van der Wer/*
SUMMARY Acute subdural hematoma, local cerebral laceration and severe brain edema must be diagnosed at the earliest possible stage preferably by angiography and must be treated promptly by craniectomy of an adequate size in order to cope with all the blood clot, the lacerated brain tissue and the swollen brain. i NTRODUCTION In this paper we will discuss acute su.bdural hematomas with or without associated brain-laceration. The condition is defined as a collection of blood in the subdural space diagnosed within 24 hours or less frequently within 48 hours after injury. In the literature several outstanding surveys have been published (MCLAURIN and TUTOR, 1961; RANSOHOFF, BENJAMIN, GAGE and EPSTEIN, 1971; JAMIESON and YELLAND, 1972, MORANTZ, ABAD, GEORGE and ROVIT, 1973, LAZORTHES et collaborateurs, 1973). At the International Symposium on head injuries held in Edinburgh and Madrid in April 1970 several papers were dedicated to this subject (CHRISTENSEN, 1971; HARRIS, 1971). MCLAURIN and TUTOR found that 8 2 % of their 90 cases operated within 24 hours had a mortality rate of 730/0. In 3AMIESON'S series these figures were 78°/0 for the first 24 hours and 6 3 % for the corresponding mortality rate. DE GROOD (1973) reports on 80 hematomas of which 720/0 were diagnosed within 24 hours and whose mortality rate was 69%. In our own series these figures are 88o/0 and 740/0 respectively (table 1).
SYMPTOMS AND SIGNS It is obvious that before an acute subdural hematoma can be operated upon an accurate diagnosis should be made. On what symptoms can this condition be * Department of neurosurgery, University Hospital Wilhelmina Gasthuis, Amsterdam, The Netherlands. Clin. Neurol. Neurosurg. 1975-3
162 Table 2
Table 1 ACUTE
SUBDURAL
Type of surgery and outcome in acute subdural hematomas
HEMATOMAS
Surgery Incidence within Mc Laurin
and
Tutor
24 hours 82%
nr.
deaths
disabled --
good
Mortality rate Burr holes
17
16
73%
Bone flap
13
9
63 %
Hemicraniectomy
14
8
Jamieson
78%
de Grood
72%
69%
own series
88%
74 %
1 4
2
3
recognised? First t h e r e is the well known free or classical lucid interval that is: the patient becomes gradually comatose (~, in table 3 and 4) or relapses in a second coma after having regained consciousness following the initial comatose episode ( / a o r ~,1' ,~). Deterioration of the state of consciousness is a major indication of the presence of an acute hematoma either extradural or subdural. Initial coma is found more often in subdural blood collections than in epidural hematomas indicating the presence of cerebral concussion or contusion in the former. Many patients, however, have no lucid interval but are unconscious throughout (,~ in table 3 and 4); this was the case in 5 0 % of ,IAMIESON'S patients who had a subdural hematoma with brain laceration. Deepening of the coma, pupillary changes and focal neurological signs will then lead to the correct diagnosis. If there is strong suspicion of a hematoma and a shift is found on the ultrasonic echogram a carotid angiogram may be very helpful to locate the exact site of the hematoma or laceration. Many times, however, the poor condition of the patient will not allow further delay of surgery. Nevertheless, whenever time permits, an angiogram should be made. Nowadays computer tomography becomes more and more available. This technique permits the distinction between edema and blood collection. JAMIESON and YELLAND (1972) discuss the significance of the various symptoms and signs in detail. As one would expect, bilateral fixed dilated pupils and decerebrate rigidity carry a very high mortality; the combination of both signs even reaches the figure of 95°/.. They conclude that operation in these cases is unlikely to be rewarding unless an extradural hematoma is found. KdELLBERG and PnlZa-O (1971) were somewhat more succesful with their bifrontal craniectomy.
TYPE OF OPERATION
One has the choice between burr holes, subtemporal decompression and osteoplastic boneflaps. Burr holes are seldom sufficient in the treatment of acute hematomas. ,IAMIESON and YELLAND report that only 6 % of the burr holes
163
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SUMMARY Acute subdural hematoma, local cerebral laceration and severe brain edema must be diagnosed at the earliest possible stage preferably by angiography and must be treated promptly by craniectomy of an adequate size in order to cope with all the blood clot, the lacerated brain tissue and the swollen brain. i NTRODUCTION In this paper we will discuss acute su.bdural hematomas with or without associated brain-laceration. The condition is defined as a collection of blood in the subdural space diagnosed within 24 hours or less frequently within 48 hours after injury. In the literature several outstanding surveys have been published (MCLAURIN and TUTOR, 1961; RANSOHOFF, BENJAMIN, GAGE and EPSTEIN, 1971; JAMIESON and YELLAND, 1972, MORANTZ, ABAD, GEORGE and ROVIT, 1973, LAZORTHES et collaborateurs, 1973). At the International Symposium on head injuries held in Edinburgh and Madrid in April 1970 several papers were dedicated to this subject (CHRISTENSEN, 1971; HARRIS, 1971). MCLAURIN and TUTOR found that 8 2 % of their 90 cases operated within 24 hours had a mortality rate of 730/0. In 3AMIESON'S series these figures were 78°/0 for the first 24 hours and 6 3 % for the corresponding mortality rate. DE GROOD (1973) reports on 80 hematomas of which 720/0 were diagnosed within 24 hours and whose mortality rate was 69%. In our own series these figures are 88o/0 and 740/0 respectively (table 1).
SYMPTOMS AND SIGNS It is obvious that before an acute subdural hematoma can be operated upon an accurate diagnosis should be made. On what symptoms can this condition be * Department of neurosurgery, University Hospital Wilhelmina Gasthuis, Amsterdam, The Netherlands. Clin. Neurol. Neurosurg. 1975-3
162 Table 2
Table 1 ACUTE
SUBDURAL
Type of surgery and outcome in acute subdural hematomas
HEMATOMAS
Surgery Incidence within Mc Laurin
and
Tutor
24 hours 82%
nr.
deaths
disabled --
good
Mortality rate Burr holes
17
16
73%
Bone flap
13
9
63 %
Hemicraniectomy
14
8
Jamieson
78%
de Grood
72%
69%
own series
88%
74 %
1 4
2
3
recognised? First t h e r e is the well known free or classical lucid interval that is: the patient becomes gradually comatose (~, in table 3 and 4) or relapses in a second coma after having regained consciousness following the initial comatose episode ( / a o r ~,1' ,~). Deterioration of the state of consciousness is a major indication of the presence of an acute hematoma either extradural or subdural. Initial coma is found more often in subdural blood collections than in epidural hematomas indicating the presence of cerebral concussion or contusion in the former. Many patients, however, have no lucid interval but are unconscious throughout (,~ in table 3 and 4); this was the case in 5 0 % of ,IAMIESON'S patients who had a subdural hematoma with brain laceration. Deepening of the coma, pupillary changes and focal neurological signs will then lead to the correct diagnosis. If there is strong suspicion of a hematoma and a shift is found on the ultrasonic echogram a carotid angiogram may be very helpful to locate the exact site of the hematoma or laceration. Many times, however, the poor condition of the patient will not allow further delay of surgery. Nevertheless, whenever time permits, an angiogram should be made. Nowadays computer tomography becomes more and more available. This technique permits the distinction between edema and blood collection. JAMIESON and YELLAND (1972) discuss the significance of the various symptoms and signs in detail. As one would expect, bilateral fixed dilated pupils and decerebrate rigidity carry a very high mortality; the combination of both signs even reaches the figure of 95°/.. They conclude that operation in these cases is unlikely to be rewarding unless an extradural hematoma is found. KdELLBERG and PnlZa-O (1971) were somewhat more succesful with their bifrontal craniectomy.
TYPE OF OPERATION
One has the choice between burr holes, subtemporal decompression and osteoplastic boneflaps. Burr holes are seldom sufficient in the treatment of acute hematomas. ,IAMIESON and YELLAND report that only 6 % of the burr holes
163
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o
~
"
~
~
u ..0
