What are the surgical interventions for patients with significant hematomas?

Surgical Interventions for Significant Hematomas

Surgical management of significant hematomas varies by location, with cerebellar hemorrhages >3 cm requiring urgent surgical evacuation, while supratentorial hematomas may benefit from minimally invasive approaches or decompressive craniectomy in select cases. 1

Intracerebral Hemorrhage (ICH)

Supratentorial ICH

• Early hematoma evacuation has not shown consistent benefit in large randomized trials for most supratentorial ICH patients 1
• Surgical intervention may be considered in specific circumstances:
  • Stereotactic surgery for patients with deep ICH 1
  • Craniotomy for patients with superficial hematomas (<1 cm from cortical surface) 1
  • Minimally invasive surgery (MIS) techniques are emerging as promising alternatives to traditional craniotomy with potentially improved outcomes 2

Cerebellar ICH

• Surgical evacuation is strongly recommended for cerebellar hemorrhages >3 cm in diameter or those associated with brainstem compression or hydrocephalus 1
• Attempting to control ICP via ventriculostomy alone is insufficient and potentially harmful, particularly in patients with compressed cisterns 1
• The perceived life-saving benefits of surgical evacuation for cerebellar ICH have prevented randomized trials comparing surgery versus conservative management 1

Decompressive Craniectomy

• May be considered to reduce mortality in patients with:
  • Coma (GCS score <8)
  • Large hematomas with significant midline shift
  • Elevated ICP refractory to medical management 1
• The effectiveness of decompressive craniectomy for improving functional outcomes remains uncertain 1
• No clear differences have been demonstrated between decompressive hemicraniectomy with and without clot evacuation 1

Subdural Hematomas

• Rapid surgical intervention is required for patients with acute subdural hematomas who present with deteriorating neurological function 3
• The subdural evacuating port system (SEPS) provides a minimally invasive technique that can be performed at bedside, which may be especially useful in areas with limited neurosurgical coverage 3

Epidural Hematomas

• Standard management has traditionally mandated prompt evacuation of all epidural hematomas 4
• Small epidural hematomas in asymptomatic patients may be managed conservatively with careful observation and repeat imaging 4
• Risk factors for subsequent deterioration requiring surgery include:
  • Skull fracture traversing a meningeal artery, vein, or major sinus
  • Early diagnosis (<6 hours after trauma) 4

Special Considerations

Coagulopathy Management

• Preoperative coagulopathy correction is crucial before surgical evacuation 5
• In patients with thrombocytopenia (<100 × 10^9/L), emergent craniotomy can be successful but prognosis may still be poor due to severe cerebral edema 5

Timing of Intervention

• For patients with significant midline shift, large hematomas, or ICP refractory to medical management, early surgical intervention should be considered 1
• In cases of cerebellar hemorrhage with brainstem compression or hydrocephalus, immediate surgical evacuation is recommended 1

Emerging Surgical Approaches

• Minimally invasive techniques are increasingly used for supratentorial ICH and include:
  • Stereotactic aspiration and thrombolysis
  • Endoport-mediated evacuation
  • Endoscopic aspiration 2
• These approaches may facilitate significant hematoma volume reduction with potentially less morbidity than conventional open surgical approaches 2

Post-Surgical Management

• Close monitoring for rebleeding and increased intracranial pressure is essential 5
• For large defects following evacuation, appropriate reconstruction techniques should be considered 6