What is a hematoma evacuation?

What is a Hematoma Evacuation

Hematoma evacuation is a surgical procedure to remove accumulated blood from tissue spaces, performed either through open craniotomy, minimally invasive techniques, or bedside wound opening, depending on the location and clinical urgency.

Definition and Purpose

Hematoma evacuation refers to the surgical removal of blood that has collected in tissue spaces following trauma, surgery, or spontaneous bleeding. 1 The procedure aims to:

• Relieve mass effect and tissue compression that can lead to ischemia and necrosis 1
• Prevent neurological deterioration in intracranial hemorrhages 2
• Restore tissue perfusion by reducing elevated tissue pressure 1
• Prevent skin necrosis in superficial hematomas under tension 3

Location-Specific Techniques

Intracranial Hematomas

Cerebellar hemorrhages require immediate surgical evacuation via craniotomy when patients show neurological deterioration, brainstem compression, or hydrocephalus, as this represents a life-saving intervention. 2 Ventricular catheter placement alone is insufficient and potentially harmful, particularly with compressed cisterns. 2

For supratentorial intracerebral hemorrhages, the approach varies:

• Standard craniotomy: Involves creating a large bone flap to access and remove the hematoma, though this requires cutting through uninjured brain tissue for deep hemorrhages 2
• Minimally invasive techniques: Use stereotactic guidance with thrombolytic-enhanced aspiration (often with tissue plasminogen activator) or endoscopic-enhanced aspiration, achieving 70-85% clot removal with reduced perilesional edema 2, 4
• Decompressive craniectomy: May be performed with or without hematoma evacuation for patients in coma with large hematomas, significant midline shift, or refractory elevated intracranial pressure 2

Post-Thyroid Surgery Neck Hematomas

Immediate bedside evacuation is mandatory when airway compromise develops, using the SCOOP approach: Skin exposure, Cut sutures, Open skin, Open muscles (superficial and deep layers), Pack wound. 5 This must be performed without waiting for stridor, which is a late sign. 5 A post-thyroid surgery emergency box must be available at bedside. 5

Subcutaneous and Extremity Hematomas

These can be evacuated using:

• Needle aspiration with suction techniques: Creating vacuum pressure through cylinder syringe suction after small incision 6
• Open evacuation under local anesthesia: Performed in wound clinic settings for hematomas causing tissue pressure or persistent symptoms 1, 3
• Percutaneous mechanical thrombectomy: For persistent post-surgical hematomas in single-setting procedures 7

Clinical Indications for Evacuation

Absolute Indications (Immediate Evacuation Required)

• Cerebellar hemorrhage >3 cm with brainstem compression or hydrocephalus 2
• Signs of airway compromise in neck surgery patients (difficulty swallowing, swelling, anxiety, tachypnea, stridor) 5
• Progressive neurological deterioration regardless of hematoma size 8
• Subdural hematoma >5mm thickness with >5mm midline shift 8

Relative Indications (Case-by-Case Consideration)

• Supratentorial hemorrhages as life-saving measure in deteriorating patients 2
• Subcutaneous hematomas under tension to prevent skin necrosis 1, 3
• Lobar hemorrhages within 1 cm of cortical surface (though evidence shows only trend toward benefit) 2

Timing Considerations

The optimal timing remains controversial, with studies reporting surgical windows from 4 to 96 hours. 2 Key timing principles:

• Ultra-early craniotomy (<4 hours) carries increased rebleeding risk 2
• Surgery within 8 hours may improve outcomes based on meta-analysis of 2186 patients 2
• Surgery before 21 hours showed trend toward better outcomes in subgroup analysis 2
• Hemorrhage most frequently occurs within first 24 hours postoperatively, requiring hourly observations for first 6 hours 5

Critical Pitfalls to Avoid

• Never delay surgical intervention when neurological deterioration is present, as this significantly worsens outcomes 5, 8
• Do not wait for stridor in neck surgery patients; intervene based on earlier DESATS criteria (Difficulty swallowing, Early warning score increase, Swelling, Anxiety, Tachypnea, Stridor) 5
• Avoid needle aspiration alone for suspected hematomas due to infection risk 5
• Do not use ventricular catheter alone instead of cerebellar hematoma evacuation 2
• Do not remove ischemic brain tissue; focus only on hematoma evacuation 8

Outcomes by Location

For supratentorial intracerebral hemorrhages, most randomized trials show no clear mortality or functional outcome benefit from routine evacuation. 2 The STICH trial found no benefit from early (<24 hours) evacuation in 1033 adults. 2

However, cerebellar hemorrhages show dramatic outcome differences with surgical evacuation versus medical management, such that clinical equipoise does not exist for randomized trials. 2

Minimally invasive approaches demonstrate better outcomes than standard craniotomy in recent studies, with significant reduction in perihematomal edema and trend toward improved neurological outcomes. 2