INTRACRANIAL HARM ATOM A
Most intracranial haematomas require urgent evacuation - evident from the patient's clinical state combined with the CT scan appearance of a space-occupying mass.
Using the CT scan the position of the extradural haematoma is accurately delineated and a 'horse shoe' craniotomy flap is turned over this area, allowing complete evacuation of the haematoma. For low temporal extradural haematomas, a 'question mark' flap may be more suitable. If patient deterioration is rapid, a burr hole and craniectomy positioned centrally over the haematoma may provide temporary relief, but this seldom provides adequate decompression.
Subdural/intracerebral haematoma ('burst lobe')
Subdural and intracerebral haematomas usually arise from lacerations on the under-surface of the frontal and/or temporal lobes. Again the CT scan is useful in demonstrating the exact site. A 'question mark' flap permits good access to both frontal and temporal 'burst' lobes. The subdural collection is evacuated and any underlying intracerebral haematoma is removed along with necrotic brain. N.B. Burr holes are insufficient to evacuate an acute subdural haematoma or to deal with any underlying cortical damage.
Conservative management of traumatic intracranial haematomas
Not all patients with traumatic intracranial haematomas deteriorate. In some, the haematomas are small and clearly do not require evacuation. In others, however, the decision to operate or not proves difficult, e.g. the CT scan may reveal a moderate-sized haematoma with minimal or no mass effect in a conscious but confused patient.
If conservative management is adopted, careful observation in a neurosurgical unit is essential. Any deterioration indicates the need for immediate operation. In this group of patients, intracranial pressure monitoring may serve as a useful guide. An intracranial pressure of 30 mmHg or more suggests that haematoma evacuation is required as the likelihood of subsequent deterioration with continued conservative management would be 226 high.
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