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 sub-
dural 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 1 Table 2

Type of surgery and outcome

ACUTE SUBDURAL HEMATOMAS in acute subdural hematomas

Surgery nr. deaths disabled good

Incidence within 24 hours Mortality rate
Burr holes 17 16 -- 1
Mc Laurin and Tutor 82% 73% Bone flap 13 9 4

63 % Hemicraniectomy 14 8 2 3
Jamieson 78%

de Grood 72% 69%

own series 88% 74 %

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 osteo-
plastic boneflaps. Burr holes are seldom sufficient in the treatment of acute
hematomas. ,IAMIESON and YELLAND report that only 6 % of the burr holes
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made in the first 24 hours were adequate. In our series of 17 patients who only
had burr holes, 16 died which means equally a 6°/0 adequacy. DE ~ROOD (1973),
however, found no difference in effectiveness of 37 burr holes and 46 bone flaps
in the treatment of acute subdural hematomas.
In both the mortality rate was 54% irrespective of the time of surgery and 69°/0
in the first 24 hours. For JAMIESON a subtemporal decompression is the operation
of choice. After a low exploratory temporal burr hole a fronto-temporal craniec-
tomy extending on either side of the sphenoidal ridge is made. He claims
that this exposure gives sufficient access to the subdural clot and to the frontal
and temporo-basal brain-laceration. Osteoplastic flaps were only used in 10%
of the patients, in case the brain lesions or residual hematoma were located at
some distance. The wound had to be reopened in 13.5% of JAMIESON's patients,
mostly for recurrent hematoma.
We have made temporo-parietal bone-flaps or very large craniectomies, so
called hemicraniectomies as described by RANSOHOFF et al in 1971. We feel that
an extensive exposure is necessary for complete removal of all subdural clot
with control of all bleeding-points and excision of lacerated brain-tissue. At the
same time a huge craniectomy with discard of the boneflap offers a good de-
compression for the inevitable postoperative cerebral edema.

TECHNIQUE AND HEMICRANIECTOMY

Our .operative technique is the same as that described by RANSOHOFF et al.

Under general anesthesia a skin incision is made running from the glabella along
the midsagittal line towards a point a few centimeters above the occipital protu-
berance and then laterally along the transverse sinus (figure 1). Via cuts between
a great number of burr holes half of the cranial vault over the entire hemisphere
is taken off. The craniectomy has to be carried far down to the base of the
temporal fossa (figure 2). The tight dura is opened over the entire brain-surface
exposing all clot, bleeding veins or sometimes arteries and macerated brain
tissue. The latter is excised and sometimes an exploded temporal lobe is resected.
The herniated temporal uncus can be freed from the tentorium until the cerebro-
spinal fluid emerges from the basal cisterns. In some cases the tentorial edge is
cut to avoid recurrent herniation. If sufficient space is obtained to close the dura
without tension, we do so; otherwise the dura is just laid back over the brain
surface and left open or closed losely with temporal muscle. We put the boneflap
in the bone bank (figure 2) and place it back when the patient is in good condi-
tion again whioh happened to be after a few weeks in several cases (figure 4).
Replacement of half of the cranial vault has proven to be relatively simple. The
bone can be autoclaved and stored, after being cleaned of all non-osseous soft
tissue and can be replaced with minimal risk of infection. In one patient we have
made a bilateral hemicraniectomy leaving only a small strip of cranial bone over
the sagittal sinus and over the suboccipital region to allow him to rest on his
166

Fig. 1. The skin incision runs from mid-

frontal along the midsagittal line to the
occiput and laterally along the transverse Fig. 2. Extent of bone defect in a hemi-
sinus. craniectomy.

Fig. 3. Half of the cranial vault has been

taken away, cleaned of all soft tissue and Fig. 4. Bone flaps replaced and fixed with
stored. nylon or metal wire through small drill
burr holes.
 167

Bifrontal cranlotomy/'or cerebral edema

Skln lnClSlOn

Ezposed dura

Fig. 5 and 6. Films of hemicraniectomised

skull in lateral and A.P. projection.
Fig. 7. Steps in the procedure of bifrontal
~0o;, ......10.
craniotomy (from Kjellberg, R. A. and
Prieto, Jr. A. reproduced with the permis-
sion of the publisher of the Journal of
Neurosurgery).

occiput. Both boneflaps were replaced in one operative session several weeks
later. Figure 5 and 6 give an idea of the extent of a hemicraniectomy. In some
cases the brain became very tense during the operation despite the large exposure
and osmotherapy. Diffuse bleeding from fractures at the base of the skull into the
basal cisterns were rest~onsible for a disastrous evolution. The brain was so
swollen that even the skin could only be closed with great difficulty.
 168

It is our experience that resection of the temporal pole of the nondominant

hemisphere in patients with umlateral brain-concussion and swelling without
much subdural hematoma may also be beneficial in selected cases.

RESULTS

We have already mentioned the fact that our burr hole cases did very badly:
16 out of 17 died. Osteoplastic boneflaps in 13 cases and hemicraniectomies in
14 fared better. These latter surgical procedures were particularly used during the
last few years. Sometimes surgery was restricted to burr holes in desparate cases
i.e. in patients considered to be too old or to have too severe brainlesions to
benefit from a more extensive decompression. One third of the patients in which
a boneflap was made or who un,derwent a hemicramiectomy survived; two of them
remained disabled: one having mental ~sturbances, the other a hemiplegia as a
result of postoperative brainabsces. Tables 3 and 4 give details concerning time
interval between trauma and operation, neurological status before surgery, shift
of midline-echo, whether or not angiography has been done, findings at operation
and postoperative management. All craniotomies have been done under general
anesthesia with controlled respiration. Postoperatively corticotherapy and anti-
osmotic drugs have been administered routinely. Postoperative controlled respira-
tion has been given only in one case.
As table 3 and 4 show subdural hematomas have been of varying thickness. In
most cases brain contusion or laceration has been present as well. Patients whose
outcome has been considered as a good one have all gone back to their former
activities.

DISCUSSION

It is not surprising that patients presenting with acute subdural hematomas and
especially those with associated brain-lacerations are in a critical condition before
operation as witnessed by the ocular signs and very often by a decerebrate
rigidity. Their natural prognosis is a mortality of almost a 100%. Up to recently
medical and surgical treatment have lowered this figure only slightly to no less
than 90 or 80% (RANSOHOFF et al, 1971, .IAMIESON,and YELLAND,1972).
An active surgical attitude with early angiographic evaluation and hemicraniec-
tomy has taken the mortality-rate down to about 60% with 280/o of the patients
returning to their former occupation, the remainder being more or less disabled,
as reported by RANSOHOFF et al. JAMIESON reports also that in acute subdural
hematomas presented within 24 hours the mortality rate was 63%. He uses more
often enlarged subtemporal decompressions than hemicraniectomies but the
clinical condition of his patients at the time of surgery, was generally somewhat
better than the patient's condition in RANSOHOFF'S series. Our clinical material
in that respect resembles more that of RANSOHOFFet al.
 169

The mortality-rates in JAMIESON'S series of decompressive procedures and in

that of HARRIS are significantly lower with 4 3 % and 5 5 % respectively but it is
very hard to compare these clinical materials. The frequency of recurrent or
residual hemorrhage is said to be consistently lower in hemicraniectomies than in
other surgical procedures (MORANTZ et al. 1973). The fear that active surgery will
lower the mortality only at the price of an increasing nttmber of crippled survivors
was fortunately not justified in .our series. Only 2 of the 27 patients who were
treated by craniotomy or craniectomy were permanently disabled, the others
being dead or back at work without m a j o r complaints.
Patients with severe brain swelling, lacerations and intracerebral blood-clot -
even without much subdural h e m a t o m a - may likewise benefit from unilateral or
occasionally bilateral hemicraniectomies.
CLAR~:, NASH and HUTCHISON (1968) advised circumferential craniotomy in
cases of pure severe diffuse cerebral oedema. The original circular craniotomy
was advocated by BAUER (1932) as a treatment for craniosynostosis; KERR in
1968 and more recently KJELLBERG and PRIETO (1971) have described methods
of radical decompression. The latter procedure consists of a large bilateral
~rontal decomoression with section of the sagittal sinus and the falx permitting
the swollen brain to bulge forward over the orbital roofs (figure 7).
These authors propose this type of decompression for cases not responding
to hyperosmotic treatment in which death is likely to supervene without surgical
intervention. Most of their patients had bilateral dilated fixed pupils, decerebrate
rigidity and absence of spontaneous respiration.
Moreover this condition - generally considered as desperate - formed the
precise indication for this operation. A m o n g 73 patients they had 13 survivors,
the survival being excellent in 5, all less than 23 years old. 870/0 of those who
died, succombed within 10 days which means that the suffering of those who will
die, is not unduly prolonged. Our own experience is restricted to one patient who
died shortly after the operation. Further appraisal will be necessary before the
usefulness of this procedure will be known.

REFERENCES

BAUER, K. H. (1932) Die Zirkuliire Kraniotomie als Entlastungstrepanation bei drohender

Turmschiidelerblindung und bei nichtlokalisierbare Hirngeschwiilsten.
Dtsch.Z.Chir. 237, 402.
CHRmTEr~SEU, .r.c. (1971) Results of Surgical Treatment in Severe Head Injuries in: Head
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CLARK, K., NASrt, T.M., HOTCmSON, ~. C. (1968) The failure of circumferential craniotomy
in acute traumatic cerebral swelling.
J.Neurosurg. 29 : 367.
GROOD, M. P. A. M. DE (1973) IS het opereren van een patiSnt met een acuut subduraal
haematoom zinvol?
Tilburg, unpublished data.
170

HARRIS, PH. (1971) Acute traumatic subdural haematomas: results of the neurosurgical care.
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