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    Atlas of Emergency Neurosurgery

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    Atlas of Emergency Neurosurgery

    Jam ie S. Ullm an , MD, FAANS, FACS

    Associate Professor, Depart m en t of Neu rosur geryHofstra Nor th Shore- LIJ School of Med icineDirector of Neurot raum aNorth Shore University Hosp it al

    Manh asset, New York

    P.B. Raks in , MD, FAANS

    Assistan t Professor, Dep art m en t of Neurosu rgeryRush University Medical Cen terDirect or, Neurosu rger y ICU

    Chief, Section Neurotrauma & Neurocritical CareJohn H. Stroger Jr Hosp ital of Cook Count y

    (form erly Cook Coun ty Hospital)Chicago, Illino is

    Medical Illustrator: Jen nife r Pryll

    Thieme

    New York Stut tgart Deh li Rio de Janeiro

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    Executive Editor: Timothy HiscockManaging Editor: Elizabeth Palum bo

    Director, Editorial Services: Mary Jo CaseyEditorial Assistant: Haley Paskalides

    Production Editor: Heidi GrauelInternational Production Director: Andreas Schabert

    Vice President, Editorial and E-Product Developme nt: Vera SpillnerInternational Marketing Director: Fiona Henderson

    Internat ional Sales Director: Louisa TurrellDirector of Sales, North Ame rica: Mike Roseman

    Senior Vice President an d Chief Operat ing O cer: Sarah Vande rbiltPresident: Brian D. Scanlan

    Print er: Asia Paci c O set

    Library of Congress Cataloging-in-Publication Data

    Atlas of em ergency n eurosu rgery / [edited by] Jam ie Ullman, P.B. Raksin.

    p. ; cm. Includes bibliographical references and index.

    ISBN 978 -1-6 040 6-36 8-4 ISBN 978 -1- 604 06-3 69- 1 (eISBN) I. Ullman , Jam ie, edit or. II. Raksin , P. B. (Patr icia B.), ed ito r.

    [DNLM: 1. Em ergen ciesAtlas es. 2. Neuros urgica l Proced ure sm eth odsAtlase s. 3. Cen tra l Ner vous System surge ryAtlas es.4. Cen tra l Nervou s System Diseasessur geryAtlase s. 5. Cran iocereb ral Trau m asurge ryAtlas es.

    6. Spina l Cord Injur iessurge ryAtlas es. 7. Spin al Injur iessur geryAtlase s. WL 17] RD593

    617 .48dc2 32015005194

    2015 Thiem e Medical Publishers, Inc.

    Thieme Publishers New York333 Seven th Avenu e, New York, NY 100 01 USA, 1-8 00- 782 -348 8custom erservice@thiem e.com

    Thieme Publishers Stuttgart

    Rdigerstrasse 14 , 70469 Stu tt gart, Germany, +49 [0]711 8931 4 21custom erservice@thiem e.de

    Thieme Publishers Delhi

    A-12, Second Floor, Sector -2, NOIDA -201301, Uttar Pradesh, India, +91 120 45 566 00custom erservice@thiem e.in

    Thieme Publishers Rio de Janeiro, Thieme Publicaes Ltda.Argentin a Building 16th oor, Ala A, 228 Praia do Botafogo Rio de Janeiro 22250- 040 Brazil, +55 21 3736-3 631

    Printed in China

    5 4 3 2 1

    ISBN 978-1 -60406 -368-4

    Also available as an e- book:

    eISBN 978-1- 60406-3 69-1

    Important note:Medicine is an ever-changing science un dergoing continu al developmen t. Research and clinical experience are contin uallyexpanding our knowledge, in par ticular our knowledge of proper treatm ent and d rug therapy. Insofar as th is book ment ions any dosage or

    application, readers may rest assured that th e authors, editors, and pub lishers have made every e ort to ensure t hat such references are inaccordance w ith the state of knowledge at the time of production of the book.

    Neve rt he les s, t hi s d oe s n ot involve , im ply, or e xp re ss a ny gu ar an te e o r r esp on sib ilit y on th e p ar t of t he pu blish er s in resp ec t to an y d osage

    instructions and forms of applications stated in th e book. Every user is requested to examin e carefullythe man ufacturers lea etsaccompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned

    therein or the contraindications stated by the m anufacturers di er from th e statemen ts made in th e present book. Such examination ispa rt icu lar ly im po rt an t w ith dr ug s t ha t ar e e ithe r r ar ely u se d o r h ave be en ne wly rele ased on th e m arket . Ever y d osage sch ed ule o r ever y

    form of application used is entirely at t he u sers own risk and responsibility. The aut hors and publishers request every user to report to th e

    pu bl ish er s a ny d iscr ep an cies or in acc ur acies no t iced . If err or s in thi s w ork a re found a fte r p ub lica t ion , er rat a w ill b e p os te d a t ww w.t h iem e.com on t he product description page.

    Some of the product names, patents, and registered designs referred to in this book are in fact registered tradem arks or proprietary nam es

    even though speci c reference to this fact is not always made in the text. Therefore, the ap pearance of a name w ithout designation aspr op riet ar y is no t to be con st ru ed as a r ep re sen tat ion by t he p ub lishe r t hat it is in t he p ub lic d om ain .

    This book, including all parts th ereof, is legally protected by copyright. Any use, exploitation, or comm ercialization ou tside th e narrow limits

    set by copyright legislation, with out the p ublishers consent , is illegal and liable to prosecution . This applies in par ticular to ph otostatreprod uction , copying, mim eograph ing, prepa ration of micro lms, and electron ic data processing and storage.

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    Contents

    Forew ord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

    Acknowledgm ents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi i

    Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi ii

    Contributo rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

    I Cerebral Traum a and Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

    Chapte r 1:Surgery for Epidural and Subdu ral Hematom as

    Shelly D. Timm ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

    Chapte r 2:Chron ic Subdu ral Hematom as

    Branko Skovrlj, Jonathan Rasouli, A. Stew art Levy,

    P. B. Rak sin , and Jam ie S. Ullman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

    Chapte r 3:Surger y for Cerebra l Cont usion s of the Front al and

    Tem po ral Lobe s, Including Loba r Resection s

    Pal S. Ran dhaw a and Craig Rabb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

    Chapte r 4:Decompressive Craniectomy for Intracranial Hypertension and

    Str oke, Includ ing Bon e Flap Stor age in Abdom ina l Fat LayerRoberto Rey -Dios and Dom enic P. Esposit o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

    Chapte r 5:Surgery for Cerebellar Stroke an d Subo ccipital Trau m a

    Faiz U. Ahm ad an d Ross Bullock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

    Chapte r 6:Elevation of Depressed Skull Fractu res

    Anan d Veeravagu , Bowen Jiang, an d Odet te A. Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

    Chapte r 7:Invasive Neurom onitor ing Techn iques

    Math ieu Laroche, Michael C. Huang, and Geo rey T. Manley . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

    Chapte r 8:Surgical Debride m en t of Penet rating InjuriesRolan d A. Torres an d P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

    Chapte r 9:Managem en t of Traum atic Neur ovascular Injur ies

    Boyd F. Richards and Mark R. Harrigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

    Chapte r 10:Managem en t of Veno us Sinu s Injur ies

    Laurence Dav idson an d Rocco A. Arm on da . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

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    Contents

    II Spinal Em ergency Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

    Chapte r 11:App lication o f Closed Spin al Tract ion

    Nirit Weiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

    Chapte r 12:Em ergency Managemen t of Odontoid Fractures

    Sanjay Yad la, Benjam in M. Zussm an , and Jam es S. Harrop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

    Chapte r 13:Cervical Burst Fractures

    Teresa S. Purzn er, Jam es G. Purzner, and Michael G. Fehlin gs . . . . . . . . . . . . . . . . . . . . . . . . . . 197

    Chapte r 14:Cer vical Facet Dislocat ion

    Daniel Resn ick an d Casey Madu ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

    Chapte r 15:Classi cation an d Treatm ent o f Thor acic Fract ures

    Joseph Hsieh , Doniel Draz in, Michael Turner, Ali Shirzadi,

    Kee Kim , and J. Pat rick Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

    Chapte r 16:Thoracolumbar Fractures

    Michael Y. Wang and Brian Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

    Chapte r 17:Spinal Epidu ral Com pression

    Asha Iyer and Arth ur Jenkins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

    Chapte r 18:Treatm ent of Acute Caud a Equina Synd rom e

    Harel Deu tsch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

    III Nontraum atic Em ergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

    Chapte r 19:Removal of Spontaneous Intracerebral Hemorrhages

    Just in Ma scitelli, Yakov Gologorsky, an d Josh ua Bederson . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

    Chapte r 20:Surgery for Acute Int racran ial Infection

    P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

    Chapte r 21:Ven tr icular Shu nt Malfunct ion

    Sergey Abeshaus, Sam uel R. Browd, and Richard G. Ellenbogen . . . . . . . . . . . . . . . . . . . . . . . . 349

    Chapte r 22:Pitu itary Apop lexy

    Kalm on D. Post an d Soriaya Motiva la . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370

    IV Em ergency Operatio ns in Co mbat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

    Chapte r 23:Com bat Cranial Oper ationsLeon E. Moores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

    Chapte r 24:Com bat-Associated Penetr ating Spine Injur y

    Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and

    Pau l Klimo Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

    V Reconstructive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

    Chapte r 25:Replacem en t of Cran ial Bone Flap

    Jam ie S. Ullm an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412Chapte r 26:Techniques of Alloplastic Cranioplasty

    Erin N. Kiehn a and John A. Jan e Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424

    Chapte r 27:Surgery for Fronta l Sinus Injuries

    Abilash Harida s and Peter J. Tau b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

    vi

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    Contents

    VI Special Considerations in Pediatric Emergency Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

    Chapte r 28:Special Cons iderat ions in th e Surgical Managem en t of

    Pediatric Trau m atic Brain Injur yAnt hony Figaji and P. David Adelson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458

    Chapte r 29:Special Cons iderat ions in Pediatric Cer vical Spine Injur y

    Pau l Klimo Jr., Nelson Ast ur Neto, W illiam C. Warner Jr., and

    Michael S. Muhlbauer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .470Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

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    viii

    Continuing Medical Education CreditInformation and Objectives

    Objectives

    1. Identify neurosu rgical conditions wh ich require em ergent or urgent intervention

    2. Evaluate the various options for man aging spine traum a in the cervical, thoracic, and thora colum bar regions.

    3. Apply provided techniques when per form ing urgent interventions for the brain and spine

    4. Recognize key issues of applying brain and spinal traum a surgical techniques to military and pediatric populations.

    Accreditation and Designation

    The AANS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical

    education for physicians.

    The AANS designates this endu ring m aterial for a m aximum of 15AMA PRA Category 1 creditsTM.Physicians should claim only the

    credits comm ensurate w ith the extent of their part icipation in the activity.

    Method of physician p articipation in th e learning process for this text book: The Hom e Study Examination is online on the AANS

    website at: http://www.aans.org/education/books/aonemergency.asp

    Estimated time to complete th is activity varies by learner, and activity equa led up to 15AMA PRA Category 1 cred itsTM.

    Release and Termination Dates

    Original Release Date: 0 5/2/2 015

    CME Term ination Date: 05 /2/2 018

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    ix

    Disclosure Information

    The AANS controls the content and production of this CME activity an d at temp ts to ensure the present ation of balanced, objective

    inform ation. In accordance with the Standard s for Comm ercial Suppor t e stablished by t he Accreditation Council for Continuing

    Medical Education, authors, planning comm ittee m em bers, sta , and any others involved in planning in education content an d the

    signi cant others of those men tioned m ust disclose any relationship they or their co-authors have with comm ercial interests wh ich

    m ay be related to the ir conten t. The ACCME de nes, relevant nan cial relationsh ips as nan cial relationsh ips in any am oun t oc-

    curring within the past 12 mont hs that create a con ict of interest.

    Those (and the signi cant others of those m ention ed) who have disclosed a relationship* with com me rcial interests are

    listed below.

    Samuel R. Browd, MD, PhD, FAANS Aqueduct Neurosciences, Inc.,

    Navison ics, Inc.

    Stock Shareholder (Direct ly purchase d?

    Harel Deutsch, MD FAANS Pioneer Honorarium, Other Financial or Material Support

    Richard G. Ellenbogen , MD, FAANS NIH/NCI

    NFL

    Paul Allen Family

    Grant - University Research Suppo rt

    Grant - University Research Supp ort , Othe r

    Financial or Material Suppor t

    Consultants

    Domenic P. Esposito, MD, FAANS(L) Integra Medical Consultants

    Michael G. Fehlings, MD, PhD, FAANS, FRCS Depuy Synthes, Medtronic Consultants, Grant - University Research Support

    Anthony Figaji, MD Codman Johnson & Johnson, Integra

    Neuroscience s

    Speakers Bureau

    Abilash Haridas, MD Uptodate, Hydrocephalus Pediatric Honorarium

    James S. Harrop, MD, FAANS Depuy Spine

    Tejin, Globus Spine, AO SPine

    Globus spine

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    Othe r Financial or Material Supp ort

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    Support r Material Support

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    Geofrey T. Manley, MD, PhD, FAANS NIH, DoD

    GE/NFL

    Grant - University Research Suppo rt

    Consultants

    Shelly D. Timmons, MD, PhD, FAANS AO Neuro Resident Neurotrauma Course Honorarium

    Michael Turner, Md, PhD Acuity Surgical Consultant

    Michael Y. Wang, MD, FAANS Depuy Spine

    Aesculap Spine, Globu s Medical

    Neuro Consulting, LLC

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    *Relationsh ip refers to receipt of royalties, consultan tship, fu nding by research grant , receiving honoraria for edu cational serv ices else-

    w here, or any other relationship to a com m ercial interest that prov ides su cient reason for disclosure.

    Those (and the signi cant others of those me ntione d) who have reported they do not have any relationship w ith comm ercial

    interests:

    Name:

    Sergey Abesha us, MD

    P. David Adelson, MD, FAANS

    Faiz U. Ahm ad, MD

    Rocco A. Arm on da , MD, FAANS

    Nels on Astur, MD

    Joshua B. Bederson, MD, FAANS

    M. Ross Bullock, MD, PhD

    Lau re nce Davidson , MD, FAANS

    Doniel Gabriel Drazin, MD

    Yakov Gologo rsk y, MD

    Mark R. Harrigan, MD, FAANS

    Odet te Alth ea Harr is, MD, MPH, FAANS

    Brian Jam es Hood, MD

    Jose ph C. Hsieh, MD

    Michael C. Huang, MDAsha Mu thuram an Iyer, MD

    John A. Jane, Jr., MD, FAANS

    Arth ur L. Jen kin s III, MD, FAANS

    Bowe n Jiang, MD

    J. Patrick Johnson, MD, FAANS

    Erin Kiehna, MD

    Pau l Klimo, Jr., MD, FAANS

    Math ieu Laroche , MD

    And rew Stew ard Levy, MD

    Just in Robert Mascitelli, MD

    Leo n E. Moores, MD, FAANS

    Corey Micha el Mossop

    Soriaya Motivala, MD

    Michae l S. Muhlb au er, MD, FAANS

    Christopher J. Neal, MD FAANS

    Kalm on D. Post, MD, FAANS

    Craig H. Rabb, MD, FAANS

    Pat ric ia B. Raksin , MD, FAANS#

    Pal Rand haw a, MD

    Jonat han Rasouli, MD

    Dan iel K. Resn ick, MD, FAANS

    Roberto Rey-Dios, MD

    Boyd Richar ds, DO

    Mich ae l K. Rosn er, MD, FAANS

    Ali Shirzad i, MDBran ko Skorvlj, MD

    Pet er J. Tau b, M D, FACS, FAAP

    Roland A. Tor re s, MD, FAANS

    Jam ie S. Ullma n, MD, FAANS#

    Anan d Veer avagu, MD

    William C. Warn er, Jr., MD

    Nir it Weiss , MD, FAANS

    Sanjay Yad la, MD

    Benjam in M. Zussm an, MD

    Casey Mad ura, MD

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    xi

    Foreword

    Simp licity is the ultim ate sophistication.

    Leonard o da Vin ci, circa 1 519

    This atlas e dited by Drs. Ullman and Raksin is clearly a very

    valuable contribution to the neurosurgical literature and

    may be best described as a quick reference atlas. Both ofthe editors are experienced neurosurgeons who have had

    decades of experience in treating patients with head and

    spinal injury. In this volume, they have brought together

    many experts in the eld to describe their approach to the

    spectrum of traum atic disorders that a ict the brain and

    spine.

    The illustrations are magni cent and th e text is direct and

    easy to follow. This st yle ensures that this book w ill be a valu-

    able guide for both residents as well as for m ore experienced

    neurosurgeons. It will serve as a quick reference before one

    embarks on treating a patient with a traumatic neurosurgi-cal disorder, or in preparing to t ake an exam ination.

    Although th ere are other texts that deal w ith neurotrauma,

    none of th em are as digestible as this one. I could wax elo-

    quent on th e m any me rits of this book. I dont n eed to. As

    you simply ip through its pages, you will see for yourself

    that this is a book w orth havingnot just to display on your

    bo oksh elf, but to keep han dy an d t o u se on an eve ryday ba -

    sis. You w ill have no tr ouble pu tt ing it to good use.

    Raj K. Narayan, MD, FACS, FAANS

    Professor an d Chairm an

    Department of NeurosurgeryHofstra North Shore LIJ School of Me dicine and

    Director, Cushing Neuroscience Institute

    Manh asset , New York

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    xii

    We would like to acknowledge and thank the a uthorskind

    colleagues, m ent ors, and dedicate d residen ts and fellowsfor

    lending their extraordinary expertise and experience to this

    project .

    We w ould like to t han k Dr. Mark Linskey, past chair of th e AANSPublications Comm ittee, for supp orting th e concept of th is at-

    las, and Dr. James Rutka, then AANS secretary, for champion-

    ing this at las to th e AANS Board of Director s. We are grat eful to

    th e AANS for its generou s grant m atched by Thiem e Publish-

    ers (to w hom we are also grateful)to fund t he illustrations.

    Thanks also go to the Executive Committee of the AANS/CNS

    Section on Neurotrauma and Critical Care for its support and

    from wh ich m any of the aut hors were selected. We are grateful

    to Dr. Michael Fehlings for his review an d coun sel regarding th e

    spine topics. We acknowledge and th ank th e Thieme ed itorial

    sta , past and presen t, for their hard work and dedication to

    this project.

    Illustrations form the backbone of this book an d, so, a special

    th ank you goes to Jenn ifer Pryll, our ne illustrator, for her

    tireless e orts in producing high-quality artwork. Ms. Pryll

    demonstrated an extraordinary level of attention to detail and

    responsiveness to the editors and au thors.

    I (JSU) want to, personally, dedicate this book to my daughter

    Sara (future singer/dancer, pediatrician, and/or neurosur geon)

    and my husband Mark for their love and patience; my dear

    family; and to t he AANS/CNS Section on Neur otra um a and Crit-

    ical Care, of which I have been an Executive Com mitt ee m em ber

    for m ore tha n 16 years and proud to b e its Chair (2014-2016).I would also like to thank my co-editor, P.B. Raksin, for her

    collaboration, patience, and diligence throughout the books

    pr od uct ion a pe rfec t m eld of m ind an d sp ir it . Finally, I w ou ld

    like to thank my colleagues and residents at the Icahn School

    of Medicine at Mount Sinai for the ir support and cont ributions

    to this atlas and over the years; and the ne attending and

    residen t sta of th e Hofstra North Shore-LIJ School of Medicine

    wh o spend long nights on call treating emergency neu rosurgi-

    cal patients.

    I (PBR) would like to acknowledge the many patients whose

    adversity has informed and enhanced my clinical experience

    (and d igital image collection) in acute care ne urosurgery over

    the p ast tw o decades. I would also like to thank m y co-editor,

    Jam ie Ullm an, for inviting me to part ner w ith her in t his project

    and en tru sting me t o help execute her vision. And, to my w ife

    Lisawh o held down the fort wh ile I pored over m anuscripts

    my eternal gratitude and a ection (and a prom ise to clean the

    o ce now that this task is complete).

    Jam ie S. Ullm an , MD, FAANS, FACS

    P.B. Rak sin , MD, FAANS

    Acknowledgments

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    xiii

    Preface

    Neu ro su rge ry is not so sim ple. Dri llin g bu r hole s in th e em er -

    gency department may relieve pressure from an expand-

    ing epidural hematoma, but the ensuing uncontrolled arte-

    rial bleeding may result in signi cant blood loss, hypoten sion,

    and death if one is not skilled in handling this situation. And,

    although trauma may be one of the more common reasonsfor emergent neurosurgical intervention, acute care for neu-

    rosurgical diseases is as widely varied as the discipline itself.

    The very eclectic nature of these emergent and urgent condi-

    tions continually challenges the skills obtained during th e long

    neurosurgery residency training period, demanding not only

    br oa d kn ow ledge an d evo lvin g t echn ica l skills, bu t pre -, in tra -,

    and p ostoperative clinical judgmen t th at can t ake a lifetime to

    m aster all for the goal of imp roving patient ou tcom es.

    Appreciation of this weighty t ask must be coupled with the idea

    that learning in neurosurgery is a decidedly visual pursuit.

    Neu rosu rgeo ns -in -t ra in ing st udy an atom ic re pre se ntat ion s,

    dissect cadavers, and observe their mentors in the operating

    room. With clinical experience and knowledge acquisition,

    there eventually comes the ability to translate the written

    words in a textbook into mental images, or to imagine ones

    waystep-by-step and with variationsthrough a p rocedure

    be fore en te ring t he o pe ra t ing t hea te r.

    The t rue value of a surgical atlas, then , lies in the pr esent ation: th e

    telling of a procedure in pictu res. Historically, atlases have bee n

    designed to guide the learner through interventions in a step-

    wise fashion. In 19 60, Jam es Leonar d Poppen , MD, published h is

    famed atlas entitled, An Atlas of Neurosurgical Techn iques. This

    tom e present ed procedu res in diagram m atic fashionuseful

    to any neurosurgeon beginning to hone his or her craft. In that

    spirit, and in th e spirit of great sur gical atlases such as Zollingers

    Atlas of Surgical Operat ions , we have set out to create a similar

    volum e devoted to emer gency neurosurgical procedures.

    This book was written for neurosurgeons-in-training, as well

    as for those already in practice who desire to meet the chal-

    lenge of whatever comes into the emergency department.

    Critical care practitioners may also nd this book bene -

    cial to understanding the surgical management of neurologic

    conditions that will demand their medical expertise in the

    post op er at ive per iod .

    The book is divided into six sect ions. Sect ion I (Chap ter s 110)

    covers the basic procedures that form the bread and butter of

    cranial neurosurgery for trauma and stroke, including crani-

    otomies for intra- and extra-axial hematoma, management of

    pe net ra t ing injur ies, an d d ecom pre ss ive cr an iect om y. Excel lent ,

    comprehensive reviews of neuromonitoring and managementof neurovascular injuries compleme nt th ese chapters.

    Section II (Chapter s 1118) focuses on spinal em ergency pro-

    ceduresboth trau m atic and nontrau mat ic. The import ant role

    of early surgery for acute traumatic spine and spinal cord in-

    ju ries is increa sin gly re cognize d; severa l chap te rs ar e de vot ed

    to operative management of these injuries. While open proce-

    dures still predominate in the emergency management of these

    entities, the increasing application of m inimally invasive tech-

    niques in this setting cannot be ignored. Chapter 16 outlines

    the minimally invasive approach to thoracolumbar trauma.

    Non t ra um at ic e m er gencies, in clu ding ep idura l sp inal com pr es -

    sion and cauda equina syndr ome, are also addressed.

    Section III (Chapters 1922) discusses the surgical managem ent

    of nontraumatic emergencies including spontaneous intracra-

    nial hem orrhage, intracranial infection, pituitary a poplexy, and

    the ever-haunting ventricular shunt malfunction. While the

    sequelae of aneurysmal ruptu re sometimes require em ergent

    surgical intervention, de nitive management often is under-

    taken m ore electively within a 12- to 72-h our per iod. The tech-

    nique of aneur ysm clipping is the subject of several imp ortan t

    tomes and is beyond the general scope of this atlas. Similarly,

    while surgery for ruptured arteriovenous malformations is of-

    ten deferred for a period of time to per mit resorpt ion of hem or-

    rhage, patients may present with life-threatening acute bleeds

    that necessitate eme rgent intervent ion for relief of m ass e ect.These clinical scenarios are addressed in Chapter 19.

    While only a select few neur osurgeons have participated in the

    theater of war, we felt it would be valuable to include a section

    addressing eme rgency intervent ions for ne urologic injuries in

    comb at (Section IV, Chapt ers 23 and 24). Key lessons lear ned

    over the pa st two de cades of con ict have led to increased sur-

    vival from th ese devastating injuries. With th e looming th reat

    of terrorism , we m ust be prepared to app ly these techniques in

    civilian populations should the need arise.

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    Section V (Chapters 2527) encompasses basic tenets of re-

    constructive surgery. The management of frontal sinus inju-

    ries requires a combination of acute care and reconstructive

    approaches. Any consideration of decompre ssive craniectomy

    would not be comp lete without a discussion of its natu ral con-

    sequence: the need for additional, mostly elective, surgery

    to restore the cranium to its original protective purpose. The

    inform ation provided is designed to help the surgeon nish

    the job.

    Finally, Sect ion VI (Chap ters 2 8 and 29) consider s concern s spe-

    ci c to the treat me nt of head and spinal injuries in the pediatric

    pop ulat ion , inclu ding st ep s for t he re con st ruct ive re pair of le p -

    tom eningeal cysts. These chapters are designed to highlight key

    di erences in the acute, and delayed, managem ent of injuries in

    children as compare d with ad ults.

    The chapters follow a standardized format. Introductory

    commentary for each topic is followed by an accounting of

    indications for neurosurgical intervention and preprocedural

    considerations. The operative procedure forms the core of each

    section. For th e read ers convenience, we designed this book to

    keep illustrations and procedural steps in close proximity. In

    addition, many steps are repeated across chapters (with varia-

    tion) to keep m ost of the chapte rs self-contained. Many of the

    pr oce du ra l st ep s ar e accom pan ied by pe ar lsa dd it ion al w is-

    dom from the subject experts, geared toward enhancing an

    operations success and avoiding complications. Each chapter

    concludes w ith a discussion of postoperative m anageme nt an d

    special conside ration s relevant to that top ic. References are kept

    to a minimum.

    As the practice of neurosurgery is as m uch an ar t as it is a sci-

    ence, there will be nuances and approaches preferable to each

    individual surgeon, and there are often several ways to ac-

    complish the sam e goal. The p rocedures outlined in t his book

    represent the best practices of the various authors and can be

    mod i ed based on surgeon experience, preference, and patient

    characteristics. And, although we have made every attempt

    to provide a comprehensive overview of the most commonly

    encountered emergency procedures, it is inevitable that other

    emergency conditions will arise that fall outside the scope of

    this project. It is our hope that the information presented in

    this book will serve as a platform upon which to build strat-

    egies for treating more complex or less common emergency

    pr esen tat ion s.

    Jam ie S. Ullm an , MD, FAANS, FACS

    P.B. Rak sin , MD, FAANS

    Prefacexiv

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    xv

    Contributors

    Sergey Abesh aus, MD

    Department of Neurosurgery

    Seattle Children s Hospit al

    Seattle, Washington

    P. David Adelson, MD, FACS, FAAP

    DirectorDiane and Bruce Halle Endowed Chair in

    Pediatric Neurosciences

    Chief, Pediatric Neuro surger y

    Barrow Neurological Institute at Phoenix

    Children s Hospital

    Phoenix, Arizona

    Faiz U. Ahm ad, MD, MCh

    Assistant Professor of Neurosurgery

    Emo ry Universit y

    Grady Memorial Hospital

    Atlant a, Georgia

    Rocco A. Armonda, MD

    Division of Neur osurger y

    Walter Reed National Military Medical Cent er

    Bethesda, Maryland

    Nelson Astu r Neto, MD

    Departm ent of Orth opedic Surgery

    Cam pbell Clinic Ort hop aed ics

    Mem phis, Tenn essee

    Josh ua Bederso n, MD

    Professor a nd Chair

    Department of Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New York

    Samuel R. Browd, MD, PhDDirector

    Departm ent of Neurosurgery an d Oncology

    Cent er for Inte grative Brain Research

    Seattle Children s Hospit al

    Harborview Medical Center

    University of Washington Medical Center

    Seattle, Washington

    Ross Bullock, MD, PhD

    Professor of Neurosurgery

    Universit y of Miami

    Director, Clinical Neurotra um a

    Jackson Hospit al

    Miami, FloridaLauren ce Davidso n, MD

    Sta Neurosurgeon

    Division of Neuro surger y

    Walter Reed National Military Medical Cent er

    Bethesda, Maryland

    Harel Deu tsch, MD

    Associate Professor of Neurosu rgery

    Rush Universit y Medical Cent er

    Chicago, Illinois

    Doniel Drazin, MD

    Department of Neurosurgery

    Cedar s Sinai Me dical Cent er

    Los Angeles, California

    Rich ard G. Elle nbo ge n, MD, FACS

    Professor and Chairman

    Departm ent of Neurological Surgery

    University of Washington

    Atten ding Neurosurgery

    Harborview Medical Center

    Seattle Childrens Hospit al

    Seattle, Washington

    Dom en ic P. Espo si to , MD, FACS, FAANS

    Professor of Neurosur gery (Ret.)

    Universit y of Mississippi

    Neu ro su rgica l Cons ult an ts, LLCJackson, Mississippi

    Michael G. Feh lin gs , MD, PhD, FRCSC

    Neu ro su rgeo n

    Division of Neuro surger y

    Toront o Western Hospital

    Toront o, Ontar io, Cana da

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    Anthony Figaji, MD

    Professor and Head

    Pediatric Neurosurgery

    University of Cape Town

    Institu te for Child Health

    Red Cross Childre ns Hospit al Cape Town

    Cap e Town, South Africa

    Yakov Golog orsk y, MD

    Atten ding in NeurosurgeryMoun t Sinai Med ical Cent er

    New York, New Yor k

    Abilash Haridas, MD

    Assistant Professor of Neurosurgery

    Wayne State Universit y School of Medicine

    Pediatric Neurosurgery

    Cerebrovascular Neurosurgery

    Childrens Hospital of Michigan

    Detroit, Michigan

    Mark R. Harrigan, MD

    Associate Professor

    Universit y of Alabam a Medical Cent er

    Birmingham, Alabama

    Odette A. Harris, MD, MPH

    Associate Professor of Neuro surger y

    Director of Brain Injury

    Stan ford School of Medicine Hospital an d Clinics

    Stanford, California

    Jam es S. Harrop, MD

    Professor of Orthopedic and Neurological Surgery

    Director, Spine and Perip her al Ner ve Surger y

    Thom as Je erson University

    Philadelphia, Pennsylvania

    Brian Hood, MD

    Major USAF, MCAssistan t Professor of Clinical Medicine

    Uniform ed University of Health Sciences

    San Anto nio Military Med ical Cent er

    San Anton io, Texas

    Jos eph Hsieh, MD

    Assistan t Professor

    The Vivian L. Smith Department of Neurosurgery

    The Universit y of Texas Hea lth Cent er

    Houston , Texas

    Michae l C. Huang , MD

    Assistan t Clinical Professor of Neurological Surgery

    University of California, San Francisco

    San Francisco Genera l Hospital and Traum a Cent er

    San Francisco, Californ ia

    Asha Iyer, MD

    Resident in Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New Yor k

    John A. Jan e Jr., MD

    Associate Professor of Neurosur gery an d Pediatr ics

    Pediatrics Division Director

    University of Virginia

    Charlottesville, Virginia

    Arthu r Jen kins , MD, FACS

    Associate Professor of Neur osurger y

    Icahn School of Medicine at Moun t Sinai

    New York, New York

    Bow en Jiang , MD

    Resident in Neurosurgery

    Johns Hopkins Hospital

    Baltimore, Maryland

    J. Patrick Johnson, MD, MS, FACS

    Director of Spine Education and Neurosurgery Spine

    Fellowship Program

    Department of Neurosurgery

    Cedar s Sinai Me dical Cent er

    The Spine Institu te Foundat ion

    Los Angeles, California

    Professor of Neurosurgery

    UC Davis Medica l Cen te r

    Sacramen to, CA

    Erin N. Kiehn a, MD

    Assistant Professor of Neurosurgery

    Child ren s Hosp ita l Los Angeles

    Los Angeles, California

    Kee Kim , MD

    Associate Professor a nd Chief

    Departm ent of Spinal Neurosurgery

    Co-d irector, Spine Cent er

    University of California, Davis School of Medicine

    Sacramen to, California

    Paul Klim o Jr., MD, MPHAssociate Professor of Neur osurger y

    Universit y of Tenn essee

    Associate, Sem m es-Mur ph ey Neurologic & Spine Inst itut e

    Mem phis, Tenn essee

    Mathie u Laroche, MD, MSc, FRCSC

    Assistant Professor of Neurosurgery

    University of Montral

    Neu ro su rgeo n

    Hpital du Sacr-Coeur d e Mont ral

    Mont ral, Qube c, Cana da

    A. Stew art Lev y, MD

    Neu ro su rgeo n

    St. Ant hony Hospit al

    Chief of Neur osurger y

    Cent ura Neuroscience & Spine

    Lakewood, Colorado

    Case y Madura, MD

    Resident in Neurosurgery

    Universit y of Wisconsin Hospital an d Clinics

    Madison, Wisconsin

    Contributorsxvi

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    Geo rey T. Manley, MD, PhD,

    Professor in Residence a nd Vice Chair ma n

    Departm ent of Neurological Surgery

    Co-Director a nd Principal Investigator

    Brain an d Spin al Injur y Cen te r (BASIC)

    Chief of Neur osurger y

    San Francisco Genera l Hospital

    University of California, San Francisco

    San Francisco , Californ iaJus tin Masc itell i, MD

    Resident in Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New York

    Leo n E. Moo res, MD, MS

    Professor of Neurosurgery

    Virginia Commonwealth University

    Professor of Surger y and Ped iatrics

    Uniform ed Services Universit y

    CEO, Ped iatr ic Specialist s o f Virginia

    Director of Pediatr ic Neuro sciences

    Inova Healt h System

    Fairfax,Virginia

    Core y M. Mosso p, MD

    Neu ro su rge ry Ser vice

    Walter Reed National Military Medical Cent er

    Silver Spring, Marylan d

    Soriaya Motivala, MD

    Assistant Professor of Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New York

    Michael S. Muhlbauer, MD

    Departm ent of Pediatric Neurosurgery

    Sem mes-Mur phey Neurologic & Spine Institu te

    Clinical Assistant ProfessorUniversit y of Tenn essee

    Le Bonh eur Children s Hosp ital

    Mem phis, Tenn essee

    Chris topher J. Neal, MD

    Neu ro su rge ry Ser vice

    Walter Reed National Military Medical Cent er

    Bethesda, Maryland

    Kalm on D. Pos t, MD

    Professor and Chairm an-Emeritus

    Depart me nt s of Neurosu rgery, Oncological Sciences,

    Medicine, Endocrinology, Diabetes, an d Bone Disease

    Icahn School of Medicine at Mou nt Sinai

    New York, New York

    Jam es G. Purzn er, MD

    Resident in Neurosurgery

    Universit y of Toront o

    Toront o Western Hospital

    Toront o, Ontar io, Cana da

    Tere sa S. Purzne r, MD

    Resident in Neurosurgery

    Universit y o f Toront o

    Toront o Western Hospital

    Toront o, Ontar io, Cana da

    Craig Rabb, MD

    Professor of Neurosurgery

    Director

    Neu ro tra um a Pr ogr amOU Physicians Neuro surger y

    Oklahom a City, Oklahom a

    P.B. Raksin, MD, FAANS

    Assistant Professor, Depart me nt of Neurosurgery

    Rush Universit y Medical Cent er

    Director, Neu rosur gery ICU

    Chief, Section Neur otrau m a & Neurocrit ical Care

    John H. Stroger Jr Hospital of Cook County (formerly Cook

    County Hospital)

    Chicago, Illinois

    Pal S. Randhawa , MD

    Resident in Neurosurgery

    Universit y of Colorado

    Aurora, Colorado

    Jon athan Raso uli, MD

    Resident in Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New York

    Daniel Resnick , MD, MS

    Professor a nd Vice Chairm an

    Residency Program Director

    Co-Director, Spinal Surger y Program

    Departm ent of Neurological Surgery

    Universit y of Wisconsin School of Medicine a nd Public

    HealthMadison, Wisconsin

    Roberto Rey-Dios, MD

    Assistant Professor of Neurosurgery

    Universit y of Mississippi Medical Cent er

    Jackson, Mississippi

    Boyd F. Richards, DO

    Departm ent of Neurological Surgery

    St. John Providence Healt h System

    Michigan Spine an d Brain Surgeon s

    South eld, Michigan

    Michae l K. Ros ne r, MD

    Chief of Neuro surger y Integrate d Service

    Assistan t Professor

    Uniform ed Services Universit y

    Walter Reed National Military Medical Cent er

    Washington, DC

    Ali Shirzadi, MD

    Neu ro su rgeo n

    South Bay Brain a nd Spine

    San Jose, Califor nia

    Contributors x

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    Branko Skovrlj, MD

    Resident in Neurosurgery

    Icahn School of Medicine at Mou nt Sinai

    New York, New Yor k

    Pete r J. Tau b, MD, FACS, FAAP

    Professor of Surger y and Pediat rics

    Associate Director, Residency Training Program

    Chief, Craniomaxillofacial Surgery

    Co-Director, Cleft and Craniofacial CenterMoun t Sinai Med ical Cent er

    New York, New Yor k

    Shelly D. Tim mons, MD, PhD, FACS, FAANS

    Clinical Associate Professor of Neurosurgery

    Tem ple University

    Director of Neurotraum a

    Associate Director for Neurosciences Adult ICU, GMC

    Residen cy Program Director

    Geisinger Health System

    Danville, Pennsylvania

    Roland A. Torres , MD

    Chairm an of Neurosurgery

    Alaska Native Med ical Cent er

    Anch orage , Alaska

    Michae l Turn er, MD, PhD

    Neu ro su rge on

    Frisco Spine

    Frisco, Texas

    Jam ie S. Ullm an , MD, FAANS, FACS

    Associate Professor, Department of Neurosurgery

    Hofstra North Shore-LIJ School of Medicine

    Director of Neurotraum a

    Nor th Shore Unive rs it y Hosp it al

    Manh asset , New York

    Anand Veeravagu, MD

    Chief Residen t in Neuro surger y

    Stan ford Universit y

    Stanford, California

    Michael Y. Wang, MD

    Departments of Neurological Surgery & Rehabilitation

    Medicine

    Universit y of Miam i

    Miller School of Med icineMiami, Florida

    Will iam C. Warner Jr., MD

    Department of Orthopaedics

    Camp bell Clinic Ort hop aed ics

    Mem phis, Tenn essee

    Nirit Weiss, MD

    Assistant Professor of Neurosurgery

    Icahn School of Medicine at Moun t Sinai

    New York, New York

    Sanjay Yadla, MD, MPH

    Department of Neurosurgery

    Alexian Brothers Neurosciences InstituteElk Grove Village, Illinois

    Benjamin M. Zussm an, MD

    Resident in Neurosurgery

    University of Pittsburgh

    Pittsburgh, Pennsylvania

    Contributorsxviii

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    I Cerebral Trauma and Stroke

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    2

    Preprocedure Considerations

    Radiographic Imaging Comp ute d tom ograph y (CT) is essential to evaluate for:! The presence and size of extra-a xial hematom a! Degree of m idline shift! Appearan ce of perim esencephalic cisterns! Presence of other space-occupying lesions

    Preoperat ive imaging (Fig. 1.1).

    Medications Preoperative antibiotics: either a cephalosporin or vancomy-

    cin (if penicillin allergic) shou ld be given.

    The patient should be given seizure prophylaxis at earliestopportunity after arrival to the hospital. Evidence-based

    guidelines support the utilization of anticonvulsants for

    7 days in patient s following traum atic brain injury.4

    Fresh frozen plasma and/or other blood products/factorsshould be administered preoperatively and intraoperatively

    as need ed to correct coagulopathy.

    Operative Field Preparation The head may be positioned on a doughnut or horseshoe

    head holder, rather than a thre e-pinion head holder, to facili-

    tate m ore rapid progression to brain decompression.

    The operat ive eld should be prepa red using an iodine-ba sedsterile prep solution, provided the patien t has no iodine allergies.

    The use of chlorhexidine is controversial; produ ct insert in-formation bars th e use for procedures exposing the cerebral

    m eninges. In cases with know n bet adine or iodine allergies,

    chlorhexidine or alcohol prep can be used.

    The incisions are marked and, after nal sterile draping, in l-trated w ith 1%lidocaine w ith epinephr ine 1:100,000.

    Introduction

    Rapid evacuation of extra-axial hematomas after trauma can

    be a life -saving in te rven t ion . While th er e is no ab solu te cu t-

    o time after which patients fare worse, m any studies have

    demonstrated better outcomes with earlier evacuation. Surgi-

    cal planning mu st take into consideration th e presence of other

    intracranial lesions an d t he patients clinical status. The pres-

    ence of polytraum a, the patients hem odynam ic status,1and the

    pre se nce of coa gu lop at hy m ust be con sid er ed an d ad dr esse d

    wh ile not delaying surgical inter vention.

    Indications

    Surgical intervention is appropr iate for epidural hematomas(EDH) with the following characteristics2

    ! Glasgow Com a Scale (GCS) score 8 and anisocoria "operating room as soon as possible

    ! Hematom a volum e 30 cm 3

    ! Hematoma volume , 30 cm3but accompan ied by:# Thickness 15 m m

    # Midline shift 5 mm# GCS 8# Focal m otor de cit

    ! E aced cistern s! Deteriorating neurologic status

    Surgical intervention is appropr iate forsubdura l h em atom as(SDH) with the following characteristics3

    ! Thickness 10 mm! Midline shift 5 mm! Thickness , 10 mm and m idl ine sh ift , 5 mm but accom-pa nied b y:

    # Neurologic worsening by 2 or m ore points on the GCS# Asymm etric pupils# Fixed and dilated pupils# Intracranial pressure (ICP) 20 mm Hg

    Surgery for Epidural and SubduralHematomasShelly D. Tim m ons

    1

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    1 Surgery for Epidural and Subdu ral Hemato mas

    3

    Fig. 1 .1ad CT scan is the modality most commonly utilized in the perioperative setting. (a) Epidural hematomas demonstrate a characteristic

    convex shape (due to ad herence of t he dura at the suture lines) and are t ypically accompa nied by a (b) fracture (arrow). (c) Subdural hematomas

    by co nt rast , are not bound by sut ure s a nd assume a crescentic appea rance, layering over the conve xity. (d) A small subdural hematoma may be

    accompanied by disproportionate mass e ect and midline shift.

    c

    a b

    d

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    I Cereb ral Traum a and Stro ke

    4

    Operative Procedure

    Positioning (Fig. 1.2a, b)

    Figure Procedural Steps Pearls

    Fig. 1.2 (a, b) The head is turned so

    as to expose the operative

    hemicranium. The patient

    whose neck has not yet been

    cleared can be po sitioned

    in the cervical collar byplacing a bolster under the

    ipsilateral shoulder and the

    ipsilateral arm across the

    chest. Pressure points should

    be padded appropriately.

    The he ad may be placed on

    a foam or gel doughnut to

    expedite positioning.

    Discuss positioning with t he a nesth esiology tea m. The e ndot racheal tube (ETT) shouldexit t he cont ralateral side of t he m outh if placed orally, and shou ld be secured in place

    using tap e, ETT collar, etc. The e yes should be prote cte d from corneal abrasion by placing

    ointment under each lid and taping the lids shut.

    Allowance for central venous cathe ters, pe ripheral intravenous cathet ers, and a rterial

    lines should be m ade, with the se positioned toward t he ane sthesiology team if possible.Foley cathe ters shou ld always be placed an d should be accessible to t he ane sthesia team .

    Pin xation may also be used, but positioning on a doughnut or horseshoe he ad holdermay expedite decompression of the brain.

    The hea d should be positioned just at or slightly overhanging the end of the table and t hesterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation

    by gravity. Final draping sho uld exclude t he a nesth esia se tup, using a vert ical drape.

    An exit site for a subgaleal drain should be included in the area e xposed by the sterile d raping. Reverse Trende lenburg positioning m ay be used t o provide e levation of the head to he lp

    reduce cerebral edem a.

    a

    b

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    1 Surgery for Epidural and Subdu ral Hemato mas

    5

    Skin Incision (Fig. 1.3)

    Figure Procedural Steps Pearls

    Fig. 1.3 The skin incision

    should be planned to

    create a cranioto my

    su cient to accessthe entire hematoma.

    The question mark

    or reverse question

    mark incision

    (illustrated he re)

    is used comm only

    to access large

    traumatic extra-axial

    hematomas.

    Other skin incisions m ay be ut ilized t o evacuate smaller hematom as. However, beforecommitting to a more limited exposure, consideration should be given to the degree of brain

    swelling anticipated.

    When using a quest ion mark incision, care sho uld be t aken not t o place the incision too close tothe pinna of the ear. A margin of at least 1 cm should be used. Likewise, the vertical limb of t he

    incision should be placed at least 1 cm anterior to the trag us. The scalp may be elevated o of

    the underlying bone and retracted out of the way.

    Scalp clips may be app lied t o the scalp edges t o aid in hemo stasis. Prior to ope ning the scalp over the te mp oralis muscle, an instrum ent may be passed over

    the muscle fascia and t he skin divided down to the level of the instrument with a scalpel. The

    tem poralis m ay the n b e divided in pa rallel with th e incision using Bovie caute ry.

    Branches of the super cial and middle tem poral arteries may be encounte red and ma y beligate d an d divided sharply, or ca ute rized with t he bipolar cautery.

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    Subcutaneous Dissection (Fig. 1.4)

    Figure Procedural Steps Pearls

    Fig. 1.4 For rapid opening, the

    temporalis muscle may be

    elevated simultaneously

    with the scalp ap.

    The tem poralis muscle may be elevated o of the underlying bone using a sharppe riostea l elevator, such as a Langenbeck, o r using th e Bovie caute ry.

    The musculocutane ous ap should be protect ed from strangulation by placing drysponges (counted) behind the ap, which is the n secured using shhooks. A sponge

    soaked with irrigation infused with epinep hrine may be placed on t he und ersurface of the

    galea and muscle to aid in hem ostasis.

    Bipolar caut ery ma y be used sparingly on scalp and m uscle vessels, taking care not toshrink the galea.

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    Cranioto my (Fig. 1.5a, b)

    Figure Procedural Steps Pearls

    Fig. 1.5 (a) Bur holes are placed at the pe rimet er of the planned

    bone ap, leaving su cient bony margins so that the plating

    hardware is not located imm ediately under the skin incision

    at closure.

    A no. 3 Pen eld dissec tor is used to strip the dura o of the

    undersurface of the bone at e ach bur hole. If possible, the

    Pen eld should be used to make a communication, in this

    same plane, be tw ee n adjacent bur holes. The high-spe ed drill

    attachment is converted to a cutting bit with a footplate and

    used t o conne ct e ach pair of bur holes circumferentially.

    The bone ap should be secured in place with a nge r prior to

    making the nal cut.

    (b) As the bone ap is elevate d o of the center dura, again

    using a no. 3 Pen eld, the edge o f the ap should be securely

    grasped and eventually removed from the exposure.

    After creat ion of the bu r holes using a high-spee ddrill, bone wax is applied to t he raw bon e e dges

    where necessary. Excess wax is removed, along with

    any obstructive bone e dges dee p in the bur holes,

    with a cup curett e.

    A larger instrumen t, such a s a Lange nbeck periostea lelevator, may be used to elevate the ap, as long

    as the underlying dura is protected from the sharp

    edge of the instrume nt. The explanted bone apshould be cleared of hematom a and blood and

    place d in irrigat ion infused with a nt ibiot ics on t he

    back ta ble u nt il ready to be re place d.

    Center holes may be made later in the bone ap forepidural tack-up sutures.

    a b

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    Evacuation o f Epidural Hemato ma (Fig. 1.6)

    Figure Procedural Steps Pearls

    Fig. 1.6 As the bone ap is elevated, an epiduralhemato ma will be appreciated imme diately

    in the extradural space. This may be

    removed using irrigation and suction.

    The so urce o f bleeding sho uld be

    addressed as quickly as po ssible, utilizing

    bipolar cautery on the vesse l itself, and/or

    bone w ax on the foramen spinosum where

    the vessel enters the cranium.

    Evacuation of an ep idural hem atom a will often yield bot h organizedhemat oma and liquid blood. The hem atoma is often adherent to the

    blee ding vessel, commonly the middle m en ingeal arte ry in the ante rior

    tem poral area. This, in turn, may be associated with a fracture of the

    squamous portion of the tem poral bone.

    Other sou rces of epidural hema tom as ma y be han dled similarly. Venousepidural hematomas sometimes require application of gel foam soaked

    in thrombin and ge ntle pressure, or Bovie caute ry or bone wax to

    blee ding bone ed ges.

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    Dural Opening (Fig. 1.7)

    Figure Procedural Steps Pearls

    Fig. 1.7 The dura is opene d widely eno ugh to allow

    access to as m uch of the subdural space as

    possible in the craniotomy exposure.

    The initial dural ope ning may be made

    with a no . 11 scalpel. The dural edge s

    may then be grasped with ne-toothed

    forceps, elevated, and the remainder of the

    opening performed with ne Metzenbaum

    or teno tomy scissors. Occasionally, if the

    brain is very edematous, the opening

    may be made with a no. 1 1 scalpel over a

    groove directo r.

    For curvilinear incisions, at least 1 cm of dura should be left bet ween t hedurotomy and the bone edge to prevent retraction, causing di culty

    with closure. If the brain is signi cantly edematou s and the dura is taut,

    relaxing incisions may be ma de in the perimet er of a curvilinear incisionto prevent strangulation of the un derlying brain by the dural edge.

    The dural edge s should be secured with 4-0 braided nylon sutures, andheld in place with mosquito hemostats, either to gravity or secured to

    the drapes without undue t ension.

    The dural ap or aps should be weighte d with hem ostat s in order topre vent shrinkage during t he pro ced ure as m uch as possible .

    Dural vessels may be coagulated with th e bipolar at the e dges of the cutdura.

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    Evacuation of Subdural Hematoma (Fig. 1.8)

    Figure Procedural Steps Pearls

    Fig. 1.8 The subdural

    hem atoma (SDH) isseen overlying the

    surface of the brain

    and is evacuated with

    irrigation and suct ion.

    The sou rce of any SDH should be sough t. The source is ofte n a cor tical surface vein or arte ry.

    SDHs occasionally may em anate directly from a surface contusion. Gent le irrigation with sterile saline shou ld be used and t he en tire perimet er of the

    dural exposure explored with adequate lighting to ensure t hat t he hem atoma has been

    completely evacuated. A brain retractor blade may be used to gently depress the brain

    during this phase. Well-formed he mat omas may be grasped with biopsy forceps and ge ntly

    elevated from t he brain surface while ushing the area with ample irrigation.

    If an act ive b leeding source is ident i ed (which is not always possible), th e bleed ing shouldbe sto pped with b ipolar e lect roca ut er y, gelat in sponge so aked in th rom bin, a nd gent le

    pre ssure with a cot to n pa t tie. The site sh ould be irrigated again to ensu re n o ac tive b leeding

    prior t o dura l closure.

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    Dural Closure (Fig. 1 .9)

    Figure Procedural Steps Pearls

    Fig. 1.9 After adequate evacuation of

    the he matoma, the dura is

    closed w ith 4-0 braided nylon

    suture.

    Epidural tack-up sutures are

    placed through small drill

    holes placed around the

    perimeter of the craniotomy.

    A central epidural tacking

    stitch may be brought out

    through tw o hole s drilled in

    the bone ap.

    Closure of the dura should be a ecte d in a watertight fashion if possible. Over theconvexity, water tight closure is not impe rative. The dura m ay be closed with simple

    running, running-locking, or interrupt ed sut ures.

    For large dural defects not amenable to primary closure due to shrunken dura, tornor adhe rent dura (comm on in the elderly), and/o r brain swelling, a variety of dural

    substitute ma terials are available. The dura m ay be patche d with suturable graft

    mat erials or autog raft from t he pa tients own galea or muscle fascia, or closed with

    graft m ate rials alone.

    Prior to placing the nal few sutures, the subdural space should be irrigated a naltime. When a large subdural poten tial space re ma ins (as in the case o f an elderly

    patient and/ or one with a slack b rain), a sm all amount of irrigat ion m ay be left in the

    subdural space to lessen the risk of extensive post operat ive pne umo cephalus.

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    Bone Flap Replacement (Fig. 1.10)

    Figure Procedural Steps Pearls

    Fig. 1.10 Following evacuation of e ither an

    epidural or subdural hematom a, the

    bone ap is replaced in its anatomic

    position, using a cranial plating

    system . The central epidural tacking

    stitch is secured.

    Many types of cranial plating systems, with a variety of plate shapesand sizes, are available. These are gene rally made of titanium, which is

    nonm agnet ic, allowing for later mag net ic resonance ima ging.

    Resorbable plates and screws are available for children. Alternatively, thebone ap may be replace d with silk suture to avoid rigid xation in the

    growing skull.

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    Drain Placement (Fig. 1 .11)

    Figure Procedural Steps Pearls

    Fig. 1.11 For large aps, a subg aleal drain

    may be used to lessen the risk of

    postoperative subgaleal hematoma.

    The drain should exit from a sepa rate st ab incision, forme d with a trocar o rno. 11 knife, and should be secured at its skin exit site with a nylon stitch.

    The drain is att ached t o bulb suction.

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    Patients with severe injuries will likely have additional in-vasive neuromonitoring (an ICP, external ventricular drain,

    br ain t issue oxygen m on itor, or a com bina t ion th er eo f) to

    guide management. Invasive hemodynamic monitoring (ar-

    terial line, central venous line, Swan- Ganz cathe ter) m ay be

    indicated to assist m anagem ent in critically ill patients.

    Drains should be mon itored for outpu t every 4 hours for therst 8 hours and then every 8-hour sh ift.

    The incision and /or dressing should be m onitored for bleed-ing initially, and for eryth em a, exudate, and/or edem a subse-

    quent t o the initial postoperative period.

    Medication Postoperative antibiotics are continued for 24 hours unless

    there w as gross contam ination present at th e time of surgery,

    in which case this period may be extended .

    Seizure prophylaxis should be continued for a total of 7 daysfor pat ients w ith EDH or SDH. The presence of docum ented

    seizures may provide an indication to continue therapy be-

    yond this window.

    Hyperosmolar the rapym annitol and/or hyperton ic salinemay be indicated for ICP control depending on the clinical

    pict ur e.

    Sedation and/or neuromuscular paralytics may be indicatedto assist ICP cont rol depe ndin g on the clinical picture .

    Pressor support may be necessary to maintain adequate cra-nial perfusion pressure depe nding on th e clinical picture.

    Ongoing coagulopathy should be corrected w ith fresh frozenplas m a o r ot he r a pp ro pr iat e b loo d p ro du ct s/ facto rs .

    Radiographic Imaging Postoperative imaging (Fig. 1.12 ).

    Further Management Drains are removed on the rst postoperative day, provided

    input has slowed su ciently. If there is signi cant output , re-

    moval may be delayed another 1 to 2 days.

    The dressing is removed and the wound is cleansed withwarm water and m ild soap or shampoo after 24 hours.

    Skin sutures or staples are removed on or about postopera-tive day 10 to 14.

    Closing

    If m ass e ect has been r elieved adequately and th e brain isslack (creating dead space in which blood may accumulate

    po stop er at ively ), the pa t ients en d-t idal CO2 level should be

    allowed to rise gradually to 30 to 35 m m Hg (roughly equiva-

    lent t o pCO2of 35 to 40 m m Hg) during closure.

    If ongoing coagulopathy is observed, measure s should be t ak-en to correct clotting param eters intraop eratively.

    Sterile saline irrigation is utilized in the intradur al space. After du ral closure, copious am ounts of sterile saline infused

    with antibiotic solution (e.g., bacitracin) are u sed t o irrigate

    the wound.

    Temp oralis m uscle and fascia are reapproximated with 0-gaugebraided absorbable su tu re. The galea is closed with int er ru pted ,

    inverted, 2-0 braided absorbable suture. As the scalp closure

    proceed s, th e scalp clips may be removed success ively, by

    spreading with th e scalp clip applier or a hem ostat.

    The skin may be closed with nylon or other nonbraided su-ture, or w ith staples. External sut ure is required on t he scalp,

    as the re is not a well-developed su bcuticular layer.

    The w ound m ay be dressed in a variety of ways. The aut horpr efe rs t o app ly a st rip of nonad he re nt p et ro lat um gauze over

    sutures or stap les to prevent pulling. This base dressing, in

    tur n, is covered with n arrow gauze ban dages to absorb m inor

    oozing postoperatively. The dressing is secured with stretchy

    dressing tape, applied un der slight tension to assist incisional

    hem ostasis. Strips of dressing tape m ay be used to follow t he

    curvature of th e head parallel to the incision for close adher -

    ence. The dressing is removed after 24 hours, and the patient

    is allowed to cleanse the wound w ith mild soap and wate r.

    Postoperative ManagementMonitoring The patient should be monitored in the post-anesthesia care

    unit (recovery room), progressive care unit, or intensive

    care unit with frequent n eurologic checks, occurring at least

    hourly initially. The patient s pre operative statu s and post-

    operative course will dictate the t iming of transition to less

    intensive monitoring.

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    References

    1. Bullock MR, Chesnut RM, Clifton GL, et al. Management and

    pr ogn os is o f seve re t ra um at ic b ra in injur y. J Neur ot ra um a 2 00 0;

    17:449597

    2. Bullock MR, Chesnu t R, Ghajar J, et al. Surgical man agem ent of

    acute ep idural hem atomas. Neurosurgery 2006;58:S7S15

    3. Bullock MR, Chesnu t R, Ghajar J, et al. Surgical man agem ent of

    acute subdu ral hem atomas. Neurosurgery 2006;58:S1624

    4. Bullock et al. Ant iseizure prophylaxis . In: Guidelines for the

    Management of Severe Traumatic Brain Injury, 3rd ed. J Neu-rotrauma 2007;24: S8386

    Special Considerations

    Preoperative planning is impor tant in the m anageme nt of trau-

    matic SDHs. Planning for possible decompressive craniectomy

    must often be incorporated into the positioning, incision, and

    bo ne ap crea t ion (se e Chapt er 4) . Pat ients w ho ar e likely to

    require the bone ap to be left out include those with midline

    shift out of proport ion to the thickness of the SDH, those w ith

    e aced cisterns, those with blunt vascular injury or ischemia to

    the a ected hemisphere , or those with a signi cant amount ofunde rlying contusion.

    Fig. 1.1 2a, b Axial CT images demonstrating resolution of (a) epidural hematoma and (b) subdural hematoma.

    a b

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    16

    Chronic Subdural HematomasBranko Skovrlj, Jonathan Rasou li, A. Stewart Lev y, P.B. Raksin , and Jam ie S. Ullman2

    Introduction

    Chronic subdural hematoma (CSDH) is one of the most com-

    monly treated neurosurgical disorders in the world. The 2006

    Am erican Associat ion of Neu rological Surgeons procedural sur-

    vey reported over 43,000 bur holes performed for the evacua-

    tion of extra-axial (subdural/epidural) hematomas.1The most

    comm on patient characteristics are elderly males with or with-

    out a history of head trauma.2,3 Addit ional risk factors include a

    history of alcoholism, the p resence of an inte rnal cerebrospinal

    uid (CSF) shun t, and acquired or congenital bleeding diathe-

    sis.4CSDHs are often un ilateral, but p resent as bilateral in ap-

    proxim at ely 1 6 to 25%o f cases.3,5The most comm on presenting

    symptoms include headache, ataxic gait, confusion, aphasia,

    and var ious non speci c complaint s. If the CSDH is large and

    causes signi cant m ass e ect, paresis, seizure, and coma m ay

    ensue. Mortality statistics vary am ong institutions, but gener-

    ally range from 5 to 16%.6,7

    Several theories exist to explain the pathogenesis of CSDH.

    The prevailing hypothesis is that most start as acute subdural

    blee ds th at t r igge r a loc al in am m at or y re sp on se in the su r-

    rounding me ninges. In am m ation triggers the migration of -

    br ob last s, w hich th en crea te m em br an es that or ganize the clot

    and secrete vascular endothelial growth factor (VEGF) that, in

    turn, promotes the formation of capillaries within these mem-

    br an es .

    8

    Over tim e, these mem brane capillaries bleed and pre-vent th e blood from being reabsorbed. Hem oglobin eventually

    is broken dow n into hem osiderin, leading to the characteristic

    appeara nce of CSDH on compu ted tomography (CT)/magnet ic

    reson ance (MR) imaging (Fig. 2.1).

    Management of CSDH typically involves surgical evacuation

    of the clot and placemen t of postsurgical drains to prevent reac-

    cum ulation of blood in the subdural space. In par ticular, the use

    of drains after bur hole evacuation of CSDH has been show n to

    reduce both recurrence and m ortality at 6 m onths.9Several op -

    erative approaches are available. Bur h ole drainage is perform ed

    m ost comm only. A mini-craniotomy m ay augmen t visualiza-

    tion of the subdural space. When the radiographic appearance

    is favorable, bedside p rocedu ressuch as m inima lly invasive

    tw ist drill catheter placem ent or suction evacuationcan beused to good e ect. In addition to th ese surgical techniques,

    several small studies have suggested that dexamethasone

    thera py might show some prom ise in treating CSDH.10,11Newer

    pha rm acologica l t re at m en t , su ch as th e us e of t ra nexam ic acid

    (an antithrombolytic agent), is investigational.12 CSDH recur-

    rence rates vary among institutions, but generally range from

    8 t o 16 %.13,14Several studies have suggested that CSDH recur-

    rence rates are higher with bilateral CSDH, with large volum es

    of pneumocephalus after evacuation, and with use of antico-

    agulation therapy.13,14

    Indications

    All Procedures Subacute or chronic subdural hematoma with maximum

    thickness . 10 mm and/or midline sh ift . 7 mm

    Subacute or chronic subdu ral of any thickness causing masse ect, midline shift, or neurologic signs and symptom s.

    Minimally Invasive

    Favorable CT imaging cha racte risticsa un iform ly isodenseor hypoden se collection in t he subd ural spaceare p resent.

    This suggests the subdural hematom a is su ciently lique ed

    to perm it drainage via a ventriculostomy catheter.

    The presence of an isodense, or even slightly hyperdense,ground glass appearance is not necessarily a contraindication

    to catheter drainage. This phenom enon is seen sometimes in

    the set ting of a subacute or acute on chronic subdur al hem a-

    toma, often w ith a gradual gradient from an terior hypodensity

    to posterior hyperdensity (re ecting dependent acute blood

    mixed with the predominantly chronic hematoma). These

    usually can be drained e ectively with a bedside catheter or

    suction evacuation procedure.

    A small amou nt of acute, hyperdense subdur al blood with in alarger, mostly chronic, hypodense collection is not necessar-ily a contraindication.

    While adequate drainage can be achieved even in the pres-ence of a few subdural membranes, extensive membranes

    and m ultiple layers of subdural hem atoma (SDH) of di erent

    ages or densities m ay pose a challenge. Bur h ole drainage or

    craniotomy should be considered in this setting.

    Preprocedure Considerations

    Radiog raphic Imaging (Figs. 2 .1,2.2, and 2.3) X-ray: In general, X-ray is a poor diagnostic tool for CSDH.

    Occasionally, a plain lm of the skull may reveal a calci ed

    CSDH.15

    CT:CT is the gold-sta nda rd im aging moda lity for diagnosingCSDH. SDHs classically dem onst rate a crescen tic con gura-

    tion, as their distribution over th e cortical convexity is not

    bou nded by su t ure lin es (in con t ras t to epid u ral b leeds) .

    Mass e ect, cortical buckling, and midline shift may also

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    appear d epen ding on the th ickness and size of the clot. The

    appearan ce of blood on CT scan w ill change over t ime as

    the blood product s age (Table 2.1 ); subacute blood appears

    isodense and chronic blood, hypodense relative to brain.

    The d egree of m idline sh ift an d th ickness of subdural blood

    are useful radiographic m arkers to assist clinical decision

    Fig. 2.1 Patient with subacute subdural hematoma with a so-calledhematocrit e ect with blood of di erent densities layering in a

    dependent fashion. There is mass e ect causing mild shift and left

    ventricular e acemen t. This patient was deem ed a good candidate for

    bur hole dra inage .

    m aking regarding operative inter vention. Noncontrast CT

    usually is adequate to assess the age of the blood pr esent,

    and therefore, the likelihood t hat it w ill be drained success-

    fully via minimally invasive or open means. Contrast-en-

    hanced imaging should be considered if there is concern for

    subdura l empyema or for clarity in th e setting of a subacute

    subdural hematoma that is isodense with respect to the

    bra in t iss ue. Enhan ce m en t of co r t ical ve in s help s to de ne

    the boundary between cortex and hematom a. Contras t mayalso dem onstrate the presence of membranes .

    MRI:Magnetic reson ance im aging (MRI) is similarly sensi-tive an d speci c for diagno sing CSDH as CT scan; it is po-

    tentially more sensitive in determining size and internal

    structure.16 CT generally is preferred due to the high cost

    of MR imaging as well as the time required to perform the

    study. Similarly to CT scanning, the appe arance of subdura l

    bloo d w ill also ch an ge ove r t im e (Table 2.2 ). MRI may be

    considered for m ore detailed evaluation of mem branes and

    layers if there is concern regarding t he feasibility of catheter

    drainage.

    Medications Intravenous (IV) antibiotics should be given within 1 hour

    prior to incis ion . The u se of p ro ph yla xis in th e set t ing of m in -

    imally invasive bed side procedures is left t o th e d iscretion of

    the surgeon.

    Antiepileptic drug proph ylaxis should be a dm inistered. Sedation for bedside procedures should be adm inistered with

    caut ion. Minimize dosing or avoid sedat ion, if possible, as pa-

    tients w ith CSDH may be par ticularly sensitive to its e ects.

    One of the ben e ts of the bedside SDH drainage procedure

    is the possibility to witness rapid neurologic improvement

    a b

    Fig. 2.2a, b Large right frontoparietal subdural hemat oma causing mass e ect and right ventricular e acement . There are some sept ations within

    the mixed d ensity subdural. A small craniotom y was chosen to evacuate t he collection.

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    when minimal or no sedating medications are used. This

    stands in contrast to the delayed emergence some (often

    elderly) patients experience after bur hole drainage under

    general anesthesia. Bur hole procedures in the operating

    room can be performed under conscious sedation or gen-

    eral anesthesia as per surgeon preference or patient toler-

    ance. Craniotomies typically are performed under general

    anesthesia.

    Operative Field Preparation The hair overlying the a ected hem isphere is clipped w ith

    electric clippers.

    Sterile skin preparation is performed with povidone iodineor chlorhexidine.

    The planned incision sites are in ltrated w ith 1% lidocainewith 1:100,000 epinephrine.

    Available imaging should be studied carefully to determinethe ideal entry point for the twist drill craniostomy. The

    target is almost always more lateral than the typical inser-

    tion site for a ventr iculostomy or intracranial pressure (ICP)monitor.

    Fig. 2 .3 CT scan of a patients head with a homoge nous right hemispheric

    subdural hematom a and right to left m idline shift. This case was selected

    for twist drill craniostomy.

    Table 2.1 CT appe arance of subdural blood over time 17

    Time

    Appearance relative

    to brain parenchyma

    Hyperacute (, 24 hours)

    Acute (12 days)

    Subacut e (213 days)

    Chronic (. 14 days)

    Hypo-/isodense

    Hyperdense

    Isodense

    Hypodense

    Table 2.2 MR appe arance of subdural blood ove r time 18

    Time T1 T2

    Hyperacute (, 24 hours)

    Acute (13 days)

    Early subacute (37 days)

    Late sub acute (813 days)

    Chronic (. 14 days)

    Hypo-/isointense

    Hypo-/isointense

    Hyperintense

    Hyperintense

    Hypointense

    Hyperintense

    Hypointense

    Hypointense

    Hyperintense

    Hyptointense

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    Operative Procedure

    Bur Hole Drainage

    Positioning and Skin Incision (Fig. 2.4a, b)

    a

    b

    Figure Procedural Steps Pearls

    Fig. 2.4 The patient is positioned supine on a donut or a horseshoe, with

    the head rotated approximately 30 degrees to the contralateral

    side. A shoulder roll is placed lo ngitudinally bene ath the ipsilateral

    shoulder. The back of the bed is e levated slightly.

    Bur Holes (Right)

    Two incisionseach approximate ly 3 cm in leng thare planned along

    a line that bisect s the inte rval betwe en midline and superior tem poral

    line. The anterior incision is positione d just ante rior to coronal suture

    and the pos terior incision, over the parietal em inence.

    Small Craniotom y (Left )

    A lazy S incision is be gun from approximately 1 cm be low the

    superior tempo ral line e xtending superiorly approximate ly 2 cm

    lateral to the m idline in the parietal reg ion approximate ly 1 cm

    poste rior to the co ronal suture. The incision can be further tailored to

    the location and size of the hematoma.

    For bilate ral procedures, t he h ead is kept ina neut ral position.

    Trace out a reverse question marktypeincision over the a ect ed hem isphere. This

    will facilitate a more extensive opening, if

    necessary. The planned bur ho le incision

    sites should fall along th e sup erior limb of

    the que stion mark. If the CT appe arance of the extra-axial uid

    is both hypodense and homogene ous, it

    may be possible t o drain the collect ion

    throug h a single bu r hole.

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    Incisions and Bur Holes/Craniotomy (Fig. 2.5)

    Figure Procedural Steps Pearls

    Fig. 2.5 A no. 10 blade is used to o pen e ach incision to the leve l of pericranium. The

    pericranium is opened with Bovie electrocautery and swept to either side

    with a periosteal e levator. For the craniotomy, scalp clips are applied to the

    scalp edge s. The te mporalis is incised and is re ected w ith the skin incision.

    Self-retaining retractors are placed.

    Bur Holes (Right)

    Place a single bur hole at e ach incision site , using a round o r matchstick bur,

    perforator, or acorn drill. Apply bone wax to the bo ny edg es as nece ssary.

    Small Craniotom y (Left )

    Place bur holes at the apices of the expo sed calvarium. A footplate

    attachme nt, dental tool, or Pen eld no. 3 is used to free the underlying

    dura from the bone . Use the craniotom e to create a small bone ap,

    limited to the size o f the ope ning.

    The craniotom e is used to create a roughly ovoid ap. The bone is

    elevate dusing a blunt surgical tool to dissect any remaining dural

    attachme nts to the unde rsurface of the bo neand set aside in antibiotic

    solution.

    Bur Holes

    ! Bur holes should be 1.5 t o 2 cmin diamete r.

    Craniotomy! Resistance may be encountered

    at t he level of coronal suture,

    where the dura is more rmly

    adherent to bone.

    ! The bone ap will be 4 to 5 cm indiameter.

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    Dural Opening (Fig. 2.6)

    Figure Procedural Steps Pearls

    Fig. 2.6 Bur Holes (Right)

    Coagulate the e xpose d dura with bipolar electrocautery at each bur hole site.

    Open the dura in a cruciate fashion with a no. 11 blade. Coagulate the dural

    lea ets w ith bipolar electrocautery to prevent bleeding into the subdural space

    and to e nsure opening o f the dura across the full surface area of the bur hole.

    Upon opening the dura, there m ay be imme diate expulsion of liquid

    hem atoma. If not, a me mbrane is likely prese nt. The m em brane sho uld

    be coagulated with bipolar electrocautery and opened sharply with a

    no. 11 blade.

    Small Craniotom y (Left )

    Drill holes circumferentially at the periphery of the craniotomy site.

    Line the e dge s of the cranioto my site with thin strips of ge latin spong esoaked in thrombin. Place epidural tacking stitches circumferentially with

    4-0 braided nylon sutures.

    Open the dura in a cruciate fashion, w ith a no. 11 blade, followe d by

    tenotomy scissors.

    An oute r membrane may be present upo n ope ning of the dura. Usually, it is

    possible to develop a distinct plane between the undersurface of the dura and

    the m embrane, using a dissector and cotton patties.

    Re ect the resulting dural aps to each quadrant and secure them with4-0 braided nylon sutures.

    Bur Holes! The p osterior site should be

    opened rst to encourage

    gravitat ional drainage.

    ! Attach one suction unit to aLukens trap prior to op en ing

    the d ura in order to facilitat e

    collect ion of a specime n for

    path ology.

    Craniotomy! When subdural hemat oma is

    pre sent , the dura will have abluish hue.

    ! A 4-0 silk suture, passedthrough the periosteal dural

    layer, may be used t o lift

    the dura away from the

    underlying structures to

    facilitat e open ing.

    ! The subdural mem braneoften has a brown-green hue.

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    Hem atoma Evacuation (Fig. 2.7 )

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    Figure Procedural Steps Pearls

    Fig. 2.7 Bur Holes (Right)

    Once the initial eg ress of uid subsides, inspect each burhole site.

    Provided the brain has not expande d to ll the subdural space,

    a small red rubber cathete r may be introducedunder direct

    vision.

    Gravity irrigat ion may be performed with lukewarm saline. A x

    a 10- to 20 -mLsyringewith the plunge r rem ovedto the ope n

    end of the red rubber cathete r. Elevate the syringe, ll the ope n

    end w ith irrigation, and allow it to funne l throug h the cathe ter,

    into the subdural space. Monitor the bur hole sites during

    this process to ensure that there is communication within thesubdural space between the two holes. Alternatively, the surgeon

    may elect simply to ush irrigate betwe en the two bur holes.

    Reo rient the cathe ter within the s ubdural space as necessary to

    permit access to additional hematoma.

    Cont inue irrigation until the returning uid is predo minant ly

    clear in all directions.

    Small Craniotom y (Left )

    Coagulate the surface of the me mbrane and open it widely

    within the craniotomy eldwith the bipolar and scissors.

    There w ill be imm ediate e xpulsion of liquid hem atoma. Collecta spe cimen in the Lukens trap for patholog y. (Consider taking a

    specimen of me mbrane as w ell.)

    Use bulb irrigation with lukewarm saline to ush additional clotfrom the subdural space at the periphery of the craniotomy site.

    Membranes and se ptations can be broken apart w ith bipolar

    coagulation.

    Irrigation w ith a red rubber catheter in a syste matic,

    circumferential fashion unde r the cranioto my edg e is pe rformed

    until the returning uid is clear in all directio ns.

    Address bleeding po ints along the me mbrane and cortical surface

    with bipolar electrocautery and/or adjuvant hemo static agent s as

    necessary.

    Additional holes m ay be placed along thedistal 2 to 3 cm of the red rubber cathet er,

    taking care not to sever the t ubing.

    If the uid introduced through one holedoes not exit t he second hole, there m ay

    be an a dd itional mem bra ne th at is limiting

    comm unication. Halt irrigation a nd reassess.

    The red rubber catheter m ay be guidedin any direction where there is presumed

    to be hematoma; however, if resistance

    is encountered, do not force the catheter

    into position. It is possible for the cathe terto pene trate brain parenchyma or t o tear a

    bridg ing vein, resulting in hemorrhag e.

    If acute hemorrhage is suspected (and theuid does n ot clear with cont inued irrigation),

    consideration must b e given t o conversion

    from bu r holes to a full craniotomy.

    The me mbrane does not need t o be cutbeyond the e dges o f the cranioto my. The

    vascularized membrane can bleed, and such

    bleed ing m ay be di cult to con trol if remote

    from the craniotomy.

    Craniotomy also facilitat es ushing out of

    more organized rests of hematom a notaccessible via bur holes.

    The inner membrane, if present, is notstripped from t he surface of the brain due to

    the risk of precipitating cort ical bleeding.

    It is important to control active bleed ing.Placing gelatin sponge soaked in throm bin in

    small pieces or strips along the und ersurface of

    the bone can be helpful in stopping bleeding

    from me mbrane