acute subdural hematoma evacuation

Acute subdural hematoma accounts for 3% to 6% of brain injury, accounting for 36% of intracranial hematoma. The mortality rate is higher because of the heavier primary brain injury. The bleeding of most acute subdural hematoma is derived from the veins and arteries of the cerebral cortical contusion. It can be considered as a complication of brain contusion and laceration, that is, a compound subdural hematoma. Hematoma often occurs in the convex surface of the site of the force, as well as the frontal, temporal and base of the heel. Another less common acute subdural hematoma is caused by a tear in the bridge vein that returns to the sinus on the surface of the brain, that is, a simple subdural hematoma. The hematoma formed is often distributed over a large area of the convex surface of the brain, and is most common in the forehead. Treatment of diseases: acute subdural hematoma Indication Acute subdural hematoma removal is applicable to: 1. There is a clear intermediate awake period after injury. There is a fracture line passing through the vascular sulcus, and there are obvious symptoms of brain compression or hook-back syndrome. 2, CT or cerebral angiography, there is a large fusiform hematoma under the dura mater, and there is a mass effect, so that the midline shift. 3, confirmed by drilling and exploration of subdural hematoma. Contraindications 1, the bilateral pupil dilated, spontaneous breathing has stopped more than 1h, in a state of sudden death. 2, CT examination sees a small amount of hematoma, and no space-occupying effect, patients in general good condition, can be conservative treatment, close observation. Preoperative preparation 1. There must be a correct positioning diagnosis before surgery. In recent years, due to advances in imaging inspection technology, clinical applications such as CT, MRI, and DSA have become increasingly widespread. The relationship between the location of the lesion and the surrounding structure should be analyzed before surgery in order to select the appropriate surgical approach, to obtain the best exposure, avoid the important structure of the skull as much as possible, increase the safety of the operation and strive for good Effect. 2, skin preparation, wash the head with soap and water before surgery, shaved hair. 3. Fasting before surgery. 4, 1 h before surgery to phenobarbital 0.1g, atropine 0.4mg or scopolamine 0.3mg intramuscular injection. Surgical procedure According to the hematoma is liquid (mostly simple subdural hematoma) or solid clot (mostly complex subdural hematoma), respectively, using different methods of hematoma removal by drilling drainage or craniotomy. However, acute subdural hematoma often coexists with brain contusion and intracerebral hematoma, and most of the frontal lobe and bungee of the heel site are prone to occur on both sides. Therefore, the hematoma removal method of craniotomy is needed. 1. Incision According to the different parts of the hematoma, the corresponding bone flaps were taken respectively. Because of the most common for the frontal and bungee, the large frontal sacral flap (expanded pituitary operative bone flap) or the bilateral forehead coronary flap. Although this kind of bone flap can have a wide range of field exposure and facilitate a wide range of decompression, it still can not fully reveal the frontal and bungee and the underside of the brain, so that it is difficult to completely remove the necrotic brain tissue and stop bleeding of the bleeding source, so For severely injured, it is best to use a similarly enlarged pterional approach incision, that is, 3cm from the midline in the hairline, extending backwards, turning to the ankle before the top nodule, and then stopping in the zygomatic arch point. The flap turned forward and downward, and the frontal humerus flap turned to the temporal side. The lower boundary of the bone window was flattened and arched, and then reached the mastoid, which reached the posterior part of the axillary fossa and frontal bulge. This incision can fully reveal the frontal temporal lobe, lateral fissure, bungee and temporal lobe. This will help clear the subdural hematoma and stop bleeding and remove the contusion lesions at the bottom of the frontal and bungee. If the hematoma is bilateral, the same incision can be used on the opposite side. 2, drilling decompression First, make a small incision in the design of the ankle incision line. After the skull is drilled, the dura mater is cut, the hematoma is removed, and the brain is quickly relieved. If there is a hematoma on both sides, the contralateral hematoma is released by the same method and then the craniotomy is continued to complete the whole process of surgery. This can avoid aggravating brain shift, prevent brain swelling and cerebral cortical laceration, and damage the important structure of the brain. 3, remove the hematoma After the dural flap is opened, the blood is washed with saline and the blood on the surface of the brain at a farther part of the bone flap is washed out, and the blood clot in the field and the inactivated brain tissue are removed. Hepatic cortical hemorrhage is patiently and carefully stopped by bipolar coagulation. Then the frontal and temporal lobes were gently lifted from the anterior cranial fossa and the middle of the cranial fossa, respectively, to explore the contusion of the brain. Use an aspirator to remove inactivated brain tissue and completely stop bleeding. Finally, a large amount of physiological saline was used to flush out the blood in the field. 4, the implementation of decompression It should be subject to availability. If the injury is mainly caused by hemorrhage, the brain contusion and laceration are not heavy. After the hematoma is removed, the brain tissue has collapsed, softened, and beaten well. Only the sacral scale should be properly removed, and the diaphragm can be decompressed under the diaphragm. If the amount of hematoma is not too much, the brain contusion and laceration is heavier, there is still obvious brain swelling or acute brain swelling after the hematoma is removed, and it has been proved that there is no other part of the hematoma, and the forehead and sputum will be applied at the same time as the dehydration drug is applied. Do appropriate resection, and remove the bone flap, intracranial decompression, otherwise, severe postoperative cerebral edema and brain swelling often lead to cerebral palsy or brain stem failure, patients are inevitably dying. 5, Guan skull The blood in the wound was washed with physiological saline, and after hemostasis was completely stopped by hydrogen peroxide and electrocoagulation, the edge of the dura mater was sutured on the diaphragm, and the wound was treated with a drainage, and the incision was sutured by layer. complication In addition to the common complication that often occurs after craniotomy, special attention should be paid to: 1. Postoperative recurrent hematoma and delayed hematoma. It should be discovered and disposed of in time. 2, secondary brain swelling and cerebral edema should be properly controlled. 3, long-term coma patients prone to lung infection, water and electrolyte balance disorders, hypothalamic dysfunction and malnutrition, etc., should be treated accordingly.

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