PREOPERATIVE DIAGNOSES:
1.
Left hemispheric subacute with acute subdural hematoma with associated
mass effect and probable seizures.
2.
Etiology most likely secondary to non-accidental trauma.
POSTOPERATIVE DIAGNOSES:
1.
Left hemispheric subacute with acute subdural hematoma with associated
mass effect and probable seizures.
2.
Etiology most likely secondary to non-accidental trauma.
PROCEDURE:
1.
Left frontal craniectomy and left parietal burr hole with evacuation of
acute and chronic subdural hematomas involving the left frontal
temporoparietal region.
2.
Placement of left subdural drain.
SPECIMENS SUBMITTED: Left frontotemporal parietal subdural hematoma,
consisting of both subacute and acute blood clot.
ANESTHESIA:
General endotracheal.
PRIMARY SURGEON:
ASSISTANT:
Michael Edwards, M.D.
Paul Jackson, M.D., Ph.D.
Jennifer Zou, M.D., Ph.D.
INDICATIONS: Xxxxxx Xxxxxxxx was brought to the Intensive Care Unit on an
urgent basis with a history of having fallen onto a carpeted floor from a low
height. The circumstances surrounding his injury were very unclear. The
patient had been in the care of an aunt, and apparently had been taken away
from custody of his parents. There was some question regarding the actual
events that occurred, but the child apparently had a change in level of
consciousness, was evaluated in Watsonville. A CT scan was obtained, showing
a rather large left-sided acute subdural hematoma situated on top of a chronic
subdural hematoma. This hematoma extended from the frontal area to nearly the
occipital area. There was no skull fracture and no bruising of the scalp,
suggestive that the etiology was not direct trauma, but more likely related to
shaking or non-accidental trauma. The child was transferred emergently to
Lucile Packard Children's Hospital, where we were called.
PROCEDURE IN DETAIL: The patient was taken to the operating room. Adequate
endotracheal anesthesia was established. Mild hyperventilation was begun.
Antibiotic prophylaxis was with Rocephin 50 mg per kg. The head was shaved on
the left side and then placed on the padded horseshoe gel Mayfield headrest.
All bony prominences and peripheral nerves were padded. An arterial line,
Foley catheter, and appropriate monitors were placed. All bony prominences
and peripheral nerves were padded. The child was covered with a body warmer.
We marked out a large trauma flap, extending from the temporal area into the
parietal occipital area, and into the frontal area within the hairline. We
draped out around this area with Steri-Drapes. The skin was scrubbed for 10
minutes with Betadine scrub, painted with alcohol and DuraPrep. The skin was
re-marked. Sterile towels, Ioban drape, and sterile sheets were applied. The
skin was infiltrated with 8 cc of 0.25% local with 1:400,000 of adrenaline.
After all the appropriate drapes and monitors were placed, we opened the
anterior two-thirds of the incision from the frontal area back to the parietal
area and slightly into the temporal region with a #15 blade and a needlepoint
Bovie scalpel. Hemostasis was established with the bipolar cautery. The
scalp was elevated with the pericranium off of the skull and the region of the
coronal suture. A roll of sponges was placed beneath the skin surface, moist
sponges over the galeal surface, and the flap was retracted with scalp hooks.
Using the Midas Rex drill and the dissecting burr, a wide craniectomy was
performed, both anterior and posterior to the coronal suture. Hemostasis was
established with the bipolar cautery and bone wax. A burr hole was placed in
the posterior parietal region. The burr was approximately the size of a
nickel, the craniotomy the size of a silver dollar.
The dura was coagulated and elevated with a sharp hook. It was opened with a
#15 blade. Posteriorly, when we opened the dura, dark liquified blood,
consistent with subacute subdural hematoma, was evacuated. Fluid was
collected for pathology to document that this was a hematoma consistent of
fluid of different ages, suggesting the possibility of multiple episodes of
trauma.
We allowed the fluid pressure to equalize. We then opened the large
craniectomy defect in a similar fashion with a #15 blade and coagulated the
dura with the bipolar cautery. In this area, further liquified dark blood
exited.
We began irrigating through the craniectomy and through the burr hole with
warm Physiosol. In doing so, we could identify that the brain was pushed at
least 1.5 cm away from the inner table. We then took a very soft feeding
tube, which we advanced in the subdural space and began irrigating the
subdural space to remove blood products. In doing so, it became obvious that
there was a solid clot, consistent with acute subdural, as we had expected.
By continuously irrigating with the feeding tube, we were able to mobilize
this clot and bring it up towards the craniectomy site. In doing so, we were
able to take fine tumor forceps, or fine biopsy forceps and grasp the clot and
slowly begin advancing the clot from beneath the bone. Using continuous
irrigation from behind the clot, we were able to eventually irrigate the solid
portion of the clot, up to the level of the craniectomy and remove the rather
significant solid clot, without completing a formal frontotemporal parietal
craniotomy. This specimen of solid clot was also sent separately to Pathology
to document the different ages of the blood.
We copiously irrigated with warm Physiosol, probably using almost a liter of
irrigation. The blood loss from the operation was less than 25 cc. We
expected that the hematoma was somewhere between 50 and 75, with the maximum
of 100 cc.
After continuous irrigation and the determination that there was no further
solid clot, and that the fluid returned was nearly clear, we placed a piece of
DuraGen over the craniectomy site. A piece of Gelfoam was placed over the
posterior burr hole, but before placing the Gelfoam, a #8 rounded Blake drain
was placed in the subdural space and brought out through a separate stab wound
in the left parietal occipital region, to be hooked to a non-pressurized
drainage bag system.
We irrigated the surface of the skull with antibiotic solution. We brought
the scalpel back into position, closed the galea with inverted interrupted
#4-0 Vicryl, the skin with running #5-0 Monocryl. A drain stitch of nylon was
placed to prevent migration of the drain, and the drain was attached to a bile
bag to allow for gravity drainage, rather than suction drainage. The drapes
were removed. Xeroform gauze, Telfa, and Tegaderm dressings were applied.
The child was awoken, extubated, and transported back to the Intensive Care
Unit in guarded condition.
The child was anemic on arrival in the operating room, and blood products were
started. It was unclear whether the anemia was long-standing and old, or
related to the acute event of trauma. In either event, the low hematocrit was
corrected.
At the end of the procedure, and on arrival in the Intensive Care Unit, the
child was noted to be moving all extremities without difficulty. The needle,
sponge, and Cottonoid count was correct.