Caution
- Position the head so that the planned skull entry point sits directly above the hematoma cavity to irrigate with artificial cerebrospinal fluid.
- Simulate all trajectories of the tubular channel using the navigation system before surgery to prevent a residual hematoma.
- Remember lobar hematomas have blind spots, especially on the proximal side.
- Keep irrigating the hematoma cavity, coagulate the bleeding point ,and apply Floseal to the oozing area to achieve complete hemostasis.
- Prioritize reducing intracranial pressure over aggressive hematoma aspiration. Don’t be overly concerned by a residual hematoma on the postoperative CT.
Lobar hematoma
Case presentation
#1
A 58-year-old woman with moyamoya disease, who had been undergoing annual follow-up MRIs at our outpatient clinic,presented in a comatose state. A head CT revealed a massive hematoma in the right hemisphere.
Lesson learned
As the supervising surgeon, I should have instructed the operator to re-position the head properly and confirm the proximal blind spots of the hematoma.
Cerebellar hemorrhage
Narrative
A woman in her eighties developed a cerebellar hemorrhage with a maximum diameter of approximately 4 cm. This morning, she did not get up at home as usual, and her son checked her room and found her collapsed. At arrival at the hospital her level of consciousness was GCS 15 but gradually deteriorated. Head CT showed the fourth ventricle was obstructed, and the ventricles were mildly enlarged with concomitant hydrocephalus. Except for her advanced age, she was a good candidate for surgical treatment. As if reciting a scripted line, I explained: “With conservative treatment alone, there is a risk that her impaired consciousness will worsen, leading to death or a vegetative state. She is in a condition requiring decompression through surgery. However, even with surgery, especially given her advanced age, the extent of recovery is uncertain. For a younger patient, I would strongly recommend surgery. However, given the her advanced age, I will respect the family’s opinion regarding surgical indication.” He replied, “I can’t decide alone. I need to consult other family members before making a decision.” About ten minutes later, he indicated they wished to proceed with surgery. When I called an anesthesiologist, he replied, “Today?” in a tone that clearly implied his schedule was packed and immediate surgery was impossible. Since we had planned to use local anesthesia from the start, it didn’t matter. The surgery proceeded smoothly as routine, and the postoperative CT showed the hematoma was almost completely removed. It’s a bit late to say, but I’ve gained considerable confidence in performing this procedure.
Procedure
Under local anesthesia, a left shoulder pillow was placed, the head was rotated to the right, and secured in a horseshoe position. The head was kept horizontal, and the bed was rotated slightly to the right to elevate the trephination site as much as possible. Using navigation, the trephination site was set as the entry point, the center of the hematoma as the target, and the approach direction was determined. With local anesthesia, sufficient forward flexion of the head is difficult, and the left shoulder becomes an obstruction. A 4cm skin incision was made with a scalpel, and the muscle layer was incised with an electrosurgical knife. Muscles were dissected with the electrosurgical knife and retracted with a retractor. A hand-held drill could not be used due to interference from the left shoulder, so a perforator was used for trephination. The hole was enlarged with a drill, and the edges were trimmed with a Kerrison retractor. The dura mater was incised in a cross pattern. A cerebral surface vein ran through the center, so it was cauterized. After cauterizing and incising the pia mater, the sheath was advanced toward the target following navigation. The hematoma was reached and aspirated out. The fourth ventricle was reached, and cerebrospinal fluid outflow was confirmed. A sheet of Surgicel was placed on the floor of the hematoma cavity. Dural repair was not possible, so Surgicel was placed in the hole. Hemostasis was confirmed. The skin was sutured, and the procedure was completed.
WILLPOWER MELTDOWN SOMETIMES 