To my brother, who valiantly endured the discussed
medical condition, and fortunately evaded the need for
surgery.
Table of Contents
v
Table of Contents
Contents
Table of Contents ............................................................................................................................ v
Introduction ................................................................................................................................... vii
History....................................................................................................................................... vii
Chapter One: ................................................................................................................................. 9
Chapter One - Neurosurgical Instruments .................................................................................... 11
Chapter Two: .............................................................................................................................. 17
Chapter Two – Preoperative Phase ............................................................................................... 19
Procedural Information ............................................................................................................. 19
Acute Subdural Hematoma ................................................................................................... 19
Subacute Subdural Hematoma .............................................................................................. 19
Chronic Subdural Hematoma ................................................................................................ 19
Evacuation Technique - Burr Hole ....................................................................................... 20
Evacuation Technique - Craniotomy .................................................................................... 20
Chapter Three: ............................................................................................................................ 21
Chapter Three – Intraoperative Phase ........................................................................................... 23
Incisions .................................................................................................................................... 23
Occlusion .................................................................................................................................. 24
Chapter Four:.............................................................................................................................. 27
Chapter Four – Postoperative Phase ............................................................................................. 29
Recovery ................................................................................................................................... 29
Preparing for Discharge – Intensive Care Unit ..................................................................... 29
Discharge Instructions .......................................................................................................... 29
Works Cited .................................................................................................................................. 33
Text Sources.............................................................................................................................. 33
Neurosurgical Tools Sources .................................................................................................... 34
Picture Sources.......................................................................................................................... 35
Introduction
vii
Introduction
The brain injury discussed in this instruction
manual is called a subdural hematoma. A
subdural hematoma occurs when a blood vessel is
ruptured beneath the dura mater1, thus causing a
collection of blood to accumulate within the
restricted confines of the skull. As you can
imagine, the pressure of blood against the skull
forces brain to mutate. If left untreated, the
increase of blood could result in death.
The purpose of this instruction manual is to provide an accessible explanation of a neurosurgical
phenomenon to pre-medical undergraduate students. In other words, pre-med students could
acquire an insight into their future while better preparing for medical school. At no point should
this procedure be attempted without a license to practice medicine, as it takes years of rigorous
training to acquire the knowledge to properly execute.
History
Dating as far back as 9,000 years ago, brain surgery
is arguably the most ancient practiced medical art
(Siegfried). Then, such an art was new so drilling
into the heads of others using barbaric methods was
considered normal. Reasons for this treatment
consisted of headaches, mental illness, head
injuries, and even a broken heart (Webb).
While a broken heart would have resulted in
operation then, it takes quite a bit more convincing
now. Today, magnetic resonance imaging, or
MRI’s, are used to detect subdural hematomas.
Modern brain surgery takes ancient methods and
combines them with state-of-the-art technology to
produce the most advanced surgical procedures
known to man.
Now, the art of penetrating the skull for surgery is termed trepanation, and it accounts for an
estimated 500,000 yearly visits to the hospital for patients with a brain injury. Sadly, merely
360,000 of such surgeries are successful (The Center for Head Injury Services). On the bright
side, the evolution of time yields greater technology, lower death rates, and a deeper
understanding of the human brain.
1. Dura Mater (also, dura): A thick membrane that encloses the brain and spinal cord. The dura rests beneath the
skull.
Chapter One:
Neurosurgical Instruments
Chapter One – Neurosurgical Instruments
11
Chapter One - Neurosurgical Instruments
The following is a depiction of the instruments required for the surgery in addition to a brief
explanation:
Small Weitlaner Retractor:
Periosteal Elevator:
This is used to hold open the
surgical site.
An instrument used to clear tissue form the
surgical site.
Surgical Aspirator:
Electrosurgical Pencil:
A source of suction to rid the surgical site of
excess blood.
A heating tool used to cauterize1 and
establish hemostasis2 at the surgical sites
1. Cauterize: To burn (a portion of tissue) for the purpose of ceasing blood flow at the surgical site.
2. Hemostasis: Occurs when blood ceases to flow at a surgical site for a clear field of view.
12
Evacuation of a Subdural Hematoma
Irrigation Bottle:
3-0 Vicryl Stitching:
A solution bottle used to cleanse the surgical
site.
A stitching used to re-connect tissue.
Burr Hole Cover:
Bone Wax:
A cap to cover and protect the trepanation
site.
A wax used to acquire hemostasis and soften
the trepanation site.
Chapter One – Neurosurgical Instruments
13
Surgical Towels:
Iodine Dressing:
Surgical “blankets” to cover and keep clean
the areas outside of the surgical site.
An iodine solution for preparation of the
surgical site and prevention of infections.
Irrigation Instrument:
Forceps:
A water source to provide irrigation to the
surgical site when necessary.
An instrument used to remove excess tissue.
14
Evacuation of a Subdural Hematoma
Ioban:
Drape Sheets:
An iodine sheet placed on the surgical site to
prevent contamination.
Sheets that capture blood irrigated from the
surgical site.
Bacitracin Ointment:
Surgical Knife:
This will be used to prevent the growth of
bacteria at the surgical site ( Drugs and
Medications - Bacitracin top)
An instrument used to create incisions.
Chapter One – Neurosurgical Instruments
Surgical Drill:
A high-speed drill that is used to create burr
holes
15
Chapter Two:
Preoperative Phase
Chapter Two – Preoperative Phase
19
Chapter Two – Preoperative Phase
Procedural Information
At this point, the patient/family should be fully aware of what the surgery consists of, including
costs, risks, and other factors.
1. To start, the physician informs the family or
patient of the costs involved in the surgery.
Typically, the surgery for the removal of a
subdural hematoma costs as much as
approximately $50,000 (Kalanithi). Despite
the high cost of the procedure, the patient is
strongly recommended to continue the
surgery, as a patient’s life exceeds material
worth.
2. Second, the physician briefly explains the risks
of the procedure. There are two categories of
risks involved: That from the anesthesia, and
that from the surgery itself. Risks from the
anesthesia can include heart attacks, blood clots, and undesirable reactions. From the surgery
itself, risks may include failure of the scalp to heal, brain injury, excessive bleeding, stroke,
paralysis, and even death (Neuro Surgery PA).
3. The patient/family is then educated about what subdural hematoma is as well as the causes
and other characteristics. There are three types of subdural hematomas: acute, subacute, and
chronic.
Acute Subdural Hematoma
An acute subdural hematoma is characterized by an immediate accumulation of blood
following a severe injury (vehicle accidents, falls, physical assaults, etc.). Due to both the
severity of the condition and high risk of death, the patient should be immediately
transported to a medical facility. The result of this condition may pose permanent
physical disabilities as well as impaired mental functioning; as a result, the postoperative
phase is generally long term (NHS Choices).
Subacute Subdural Hematoma
A subacute subdural hematoma (SSH) is similar to an acute subdural hematoma in
regards to severity; however, detection of an SSH is generally delayed by days, and even
weeks post-injury. Few incidents resulting in this condition have been recorded,
therefore, little information is known (NHS Choices).
Chronic Subdural Hematoma
A chronic subdural hematoma occurs when a gradual accumulation of blood coagulates1
throughout the duration of two to three weeks post-injury. Conditions are less fatal than
that of an acute subdural hematoma; however, surgery is often required (NHS Choices).
20
Evacuation of a Subdural Hematoma
1. Coagulate: A clot (of blood)
Additionally, evacuation techniques will vary in consideration of the quality of the injury, but
generally, there are two techniques used: through a burr hole, and through a craniotomy.
Evacuation Technique - Burr Hole
The burr hole technique is a form of trepanation
that consists of drilling two holes in the patient’s
skull. One burr hole (at the anterior location1) is
inundating with an irrigation bottle, while the
other (at the posterior location2) is the exiting site
of the fluid. This is the technique discussed in this
instruction manual.
Another form of this technique involves drilling
one small hole followed by inserting a suction
tube. The suction tube will drain blood from the
subdural space.
The burr hole technique is among the least evasive and is therefore one of most used for
chronic subdural hematomas (NHS Choices).
Evacuation Technique - Craniotomy
Evacuation through a craniotomy consists of the
removing a portion of the skull. The large clot
of blood is removed via suction and irrigation.
A craniotomy is more evasive than evacuation
through a burr hole and is therefore only used in
severe cases such as acute subdural hematomas
and some chronic subdual hematoma. The
portion of the skull removed depends on case
characteristics (NHS Choices).
It should be noted that not all subdural hematomas require surgery, as it is strongly determined
by the severity of the case.
Characteristics of the subdural hematoma vary in consideration of the type, but generally
symptoms may include (but not limited to): dizziness, vomiting, mental confusion, coma,
obstruction of eyesight or other physical motions (NHS Choices).
Following the disclosure of information regarding a subdural hematoma, the patient is draped
and prepared for surgery.
1.
2.
Anterior location: An anatomical location representing the front portion of the human body.
Posterior location: An anatomical location representing the back portion of the human body.
Chapter Three:
Intraoperative Phase
Chapter Three – Intraoperative Phase
23
Chapter Three – Intraoperative Phase
To begin, the patient is rested in a supine position,
with his/her head lifted on a cerebellar headrest.
The patient is then given perioperative1 antibiotics
to prevent harmful bacteria from infecting the
surgical areas. Once administered, the patient is
anesthetized. The surgery begins.
Note: The location of incisions is made in
accordance to the characteristics of the
patient’s injury; however, much of the
procedures follow a general pattern.
Supine Position
Incisions
In this section, two linear incisions will be
marked. The first is 2-3cm (in length) marked 12cm above the superior temporal line. This mark
will be located just before the hairline. The
second linear mark will also be 2-3cm in length,
but located just behind the patients ear and
lateral to that of the first incision mark.
The area of the incision marks is then shaved. A
shave will provide a clear viewing field for the
Superior Temporal Line
neurosurgeon, as well as a sanitary environment
for the patient. Once shaved, the surgical areas
are dressed in iodine to kill harmful bacteria. Surgical towels are placed to surround the sites
with Ioban, and blood sheets placed above, respectively.
Along both marks, linear incisions are made down to the patient’s skull. A periosteal elevator is
used to clear the surrounding tissue while a weitlaner retractor is used to push the tissue clear
from the surgical area.
Hemostasis is obtained through cauterization of the site, which is accomplished with the use of
an electrosurgical pencil.
The neurosurgeon then creates a burr hole using a high speed perforating drill. During which,
both a gentle irrigation and aspiration are applied to cleanse the site.
Bone wax is then applied to achieve intracranial hemostasis2 in addition to softening the site of
trepanation This may also prevent small particles of cranial bone from entering the burr hole and
damaging the brain.
1. Perioperative: A term representing the entire timeframe surrounding the operation.
2. Intracranial Hemostasis: A type of hemostasis that occurs within the skull; the ceasing of blood flow in the skull.
24
Evacuation of a Subdural Hematoma
The same sequence of events is then completed at the posterior location
After meticulous hemostasis1 is acquired at both surgical sites, penetration of the dura is
commenced in a cruciate manner starting at the anterior location.
At this point, partial evacuation of the subdural hematoma is executed with the use of a surgical
vacuum drain.
Attention is then turned to the posterior location, where the same method of penetration is
implemented.
Once both surgical sites are fully accessible, complete
evacuation can occur. This is accomplished with the
combination of irrigation at the anterior site, and
suction at the posterior site. Figure 1.1 illustrates.
Evacuation
Note: Extra caution must be taken during this
process, as the patient’s brain is visible at this
point. Any damages to the brain may result in
catastrophe.
Any excess membranes that are unattached within the
subdural space should be removed during evacuation,
as they contribute to clotting in the subdural space.
Figure 1.1
As the evacuation proceeds, it may be noticed that the irrigation exiting the posterior location is
clear; at which point indicates that the evacuation of the subdural hematoma is complete.
Once the subdural hematoma is fully evacuated, occlusion of both burr holes may commence.
Occlusion
At this point in the procedure, both surgical sites should be at
a state of meticulous hemostasis. If so, final irrigation of both
burr holes should fill the subdural space.
Burr hole covers are then applied to both sites and secured
appropriately. This will protect the brain from small objects
entering the skull.
Once secured, a subgaleal drain2 is inserted over each site,
starting at the anterior location, and terminating at the
posterior location. This will ensure complete fluid evacuation
at a subgaleal level.
Burr Hole Covers
1. Meticulous Hemostasis: A form of hemostasis that involves ceasing blood flow in all vessels of the surgical
locations.
2. Subgaleal Drain: A tubing that is inserted below the galeal tissue.
Chapter Three – Intraoperative Phase
25
In order to eliminate devitalized tissue and small particles, a gentle irrigation is applied to both
sites once more. A thorough irrigation will prevent extracranial infections in the tissue; therefore,
it is crucial to adequately execute this step.
Once completed, 3-0 Vicryl stitches are used to rejoin the scalp tissue. The stitches will penetrate
the tissue to the subgaleal level and occlude the burr hole covers. The final occlusion process of
stapling the exposed scalp edges together is carried out. The inserted staples will secure the
tissue while preventing dehiscence.
Finally, Bacitracin Ointment is applied to each site. Bacitracin Ointment is an antibiotic used to
cease the growth of bacteria, and thus, prevent infections. After the sites are properly dressed
with the antibiotic, the combination of gauze pads and an adhesive border covers the wound.
Gauze pads will prevent bleeding while protecting the sites, and the adhesive border will hold the
gauze pads to the skin surface.
After the wound is appropriately dressed and bandaged, the patient is transferred to ICU where
he/she will be monitored for the next three days (at minimum).
Source: https://www.youtube.com/watch?v=jD3JTOaS20&list=PLu7E6jGn089z_ielY_qmuTJd0CFFmJR1h&index=12
Chapter Four:
Postoperative Phase
Chapter Four – Postoperative Phase
29
Chapter Four – Postoperative Phase
Recovery
Following the operative stage, the patient is transferred to the Post-Anesthesia Care Unit
(PACU), or most commonly referred to as, the Recovery Room. The patient will spend one to
two hours in this unit for periodic monitoring of blood pressure, neurological functions,
temperature, pulse, and respirations (Giecer).
Preparing for Discharge – Intensive Care Unit
Once the time spent in the recovery room has expired, the patient is transferred to the Intensive
Care Unit (ICU). Duration of time spent in the ICU depends strongly on the severity of the
conditions and type of hematoma that was evacuated. Characteristics of the patient’s stay in ICU
are as follows:




Pain medicine is administered as needed by injection, and later by mouth as the patient is
more active.
Limited consumption of food and liquid is permitted only after the patient has been
awake for some time.
Urine is collected through a catheter1 whereafter it is drained. The catheter is removed as
soon as the patient has gained independence.
Constipation occasionally follows such as surgery; therefore, stool softeners are
administered as needed.
Characteristics of the patient’s stay in ICU will differ with every person; as a result, more or
even less characteristics may be considered (Giecer).
Once the patient is well enough to be released, he/she is discharged.
Discharge Instructions
Upon discharge, the patient should be informed of
instructions regarding the development of negative
symptoms after the surgery has taken place. In some
cases, the patient may be recommended various
types of therapy depending on the characteristics of
postoperative symptoms (NHS Choices).
Postoperative symptoms may include the following:
Confused speech, headache, seizures, weakness in
the limbs, nausea, vomiting, numbness, etc.
(Medline Plus).
1. Catheter: A thin tube inserted into the patient’s bladder to remove urine.
30
Evacuation of a Subdural Hematoma
The patient’s day-to-day activity may be limited until otherwise authorized by a physician.
Limitations and additional instruction may include the following:









Plenty of rest. In other words, the patient should avoid any athletic activities, especially
those of which may risk an additional injury to the head. It is imperative that the patient
gives his/her injury time to heal.
A plastic wrap should be placed over the patient’s injury site prior to showering. The
plastic wrap should be removed afterwards and the dressing should be changed
immediately. Following a week after the surgery and when the stitches have been
removed, the patient may shower without a covering plastic wrap.
The development of swelling, redness,
dehiscence1 or irrigation of the wound must
be immediately reported to the appropriate
physician.
Temperature should be taken daily at 4:00
PM and if it exceeds 101 degrees Fahrenheit
(38 degrees Celsius) the appropriate
physician should be contacted.
In the case of a seizure, the patient should be
immediately transported to the emergency
room or a physician should be contacted.
The patient is permitted sexual activity
granted it does not disturb the injury site.
Any new or unusual developing symptoms should be reported to the appropriate medical
office.
Prescribed medications should be taken as instructed by the patient’s physician.
Driving is prohibited unless otherwise later authorized by the patient’s physician.
Follow-up appointments may be established
during the recovery phase and the patient should
be apt to attend. These appointments are made to
ensure full recovery of the patient; therefore,
instructions regarding these should be followed
(Neuro Surgery PA ).
It is important to note that full physical and
cognitive recovery may take years depending
on operative complications and severity of
the injury. In some cases, symptoms may be
permanent, such as fluctuations of the
patient’s mood, inability to recollect various
events, distorted concentration, and
feebleness in the patient’s limbs (NHS
Choices).
1. Dehiscence: The rupture of a surgically occluded wound.
Chapter Four – Postoperative Phase
31
Full recovery time depends solely on the severity of the condition, but several weeks should
yield positive results granted that the patient follows instructions. An office phone number and/or
email may be provided for any questions or concerns that the patient may have.
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33
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Evacuation of a Subdural Hematoma
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