From the Guidelines
Surgical intervention for a hematoma is indicated when patients with cerebellar hemorrhage are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction, and should undergo surgical removal of the hemorrhage as soon as possible. This is based on the guidelines for the management of spontaneous intracerebral hemorrhage from the American Heart Association/American Stroke Association 1.
Key Indications for Surgical Intervention
- Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B) 1.
- For most patients with supratentorial ICH, the usefulness of surgery is not well established (Class IIb; Level of Evidence A), but supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Class IIb; Level of Evidence C) 1.
Considerations for Surgical Intervention
- A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacuation when patients deteriorate (Class IIb; Level of Evidence A) 1.
- DC with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management (Class IIb; Level of Evidence C) 1.
- The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Class IIb; Level of Evidence B) 1.
Decision Making for Surgical Intervention
The decision for surgical intervention balances the risks of surgery against the potential benefits of hematoma removal, considering the patient's overall condition, comorbidities, and the specific location of the hematoma. Conservative management is preferred for stable, small hematomas without significant mass effect or neurological symptoms.
From the Research
Indications for Surgical Intervention
- A large, deep, consolidated hematoma that is hard to evacuate without an incision may require surgical removal, as seen in a case report of a 21-year-old military recruit with a large submuscular buttock hematoma 2
- Hematomas of the extremities can result in necrosis of the overlying skin due to increased tissue pressure, and prompt recognition and operative evacuation of these hematomas should be performed to avoid significant complications 3
Surgical Techniques
- Ultrasound-guided suction technique can be used to evacuate a large hematoma under local anesthesia using only a stab incision, as demonstrated in a case report 2
- Operative evacuation of hematomas can be performed using local anesthesia in the wound clinic setting, as presented in two case studies 3
Management of Hemorrhagic Complications
- Image-guided interventions can be used to manage hemorrhagic risks from percutaneous interventions, and preventative measures and treatments for postintervention bleeding should be discussed 4
- Post-operative haemorrhage requires swift recognition and management, and can be assessed using the ABCDE approach, with management interventions used to halt the bleeding and restore intravascular volume 5
Role of Ultrasound in Hematoma Management
- Ultrasound can be used to diagnose and treat hematoma and seroma, including those associated with surgical procedures, and can be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting 6