Temporizing treatment of hyperacute subdural hemorrhage by subdural evacuation port system placement

Case report

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An acute subdural hematoma (SDH) requiring surgical intervention is treated with craniotomy or craniectomy, in part because it is generally accepted that coagulated blood present in the acute phase cannot be adequately evacuated by less-invasive means such as bur hole drainage. However, a hyperacute SDH in the first few hours after trauma can have mixed-density components on CT scans that are thought to represent subdural blood that is not yet fully coagulated.

The authors report a case in which a hyperacute SDH in a patient receiving antiplatelet therapy was treated with the novel technique of temporizing subdural evacuation port system (SEPS) placement. Placement of an SEPS in the intensive care unit allowed for rapid surgical treatment of the patient's elevated intracranial pressure (ICP) by drainage of 70 ml of fresh subdural blood. After initial SEPS-induced stabilization, the patient underwent operative treatment of the SDH by craniotomy. The combined approach of emergency SEPS placement followed by craniotomy resulted in a dramatic recovery, with improvement from coma and extensor posturing to a normal status on neurological evaluation 5 weeks later. In appropriately selected cases, patients with a hyperacute SDH may benefit from SEPS placement to quickly treat elevated ICP, as a bridge to definitive surgical treatment by craniotomy.

Abbreviations used in this paper: CPP = cerebral perfusion pressure; ICP = intracranial pressure; SDH = subdural hematoma; SEPS = subdural evacuation port system.

Article Information

Address correspondence to: Alexander C. Flint, M.D., Ph.D., Department of Neurosurgery, Kaiser Permanente, Redwood City, 1150 Veterans Boulevard, Redwood City, California 94063. email: alexander.c.flint@kp.org.

Please include this information when citing this paper: published online June 17, 2011; DOI: 10.3171/2011.5.JNS1123.

© AANS, except where prohibited by US copyright law.

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    A: Initial noncontrast head CT scan demonstrating a thin right holohemispheric SDH with 0.3 cm of midline shift (left). An SDH is also seen layering over the tentorium, and subarachnoid blood is seen in the perimesencephalic cisterns (right). B: Repeat noncontrast head CT scan obtained later the same day after neurological deterioration, demonstrating interval enlargement of the right SDH with mixed density and 1.9 cm of midline shift (left). There is transtentorial herniation of the temporal uncus and mass effect on the right side of the midbrain with rightward torsion of the upper brainstem (right). C: Repeat noncontrast head CT scan acquired at the 5-week follow-up after right SEPS placement followed by right craniotomy. There is no residual SDH or midline shift (left). There is no radiological evidence of uncal herniation and the brainstem morphology appears normal (right).

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