An emergency or semi-emergency neurosurgical procedure in which an acute or chronic blood collection between the brain layers is drained through a burr-hole or craniotomy to relieve pressure on the brain.
Indication
- Acute subdural hematoma (rapidly developing dense blood collection, usually after severe head trauma)
- Subacute subdural hematoma (developing within 3-21 days, causing fluctuations in consciousness and neurological status)
- Chronic subdural hematoma (especially in the elderly, developing over weeks after minor trauma with headache, imbalance, forgetfulness, and weakness)
- Hematomas that develop and enlarge during anticoagulant (blood thinner) use
- Hematomas causing impaired consciousness, motor weakness, or speech disturbance
- Hemorrhages causing midline shift or brainstem compression on imaging
Preparation
- In emergency cases, blood typing, coagulation tests (PT/aPTT/INR), and platelet tests are completed rapidly
- If anticoagulants are being used, they are reversed with antagonist agents (e.g., vitamin K, prothrombin complex concentrate)
- Cranial CT (and MRI if needed) is used to assess the location, thickness, and structure of the hematoma
- In non-urgent chronic hematomas, 6-8 hours of fasting and preoperative evaluation for general anesthesia are performed
- Possible risks and surgical-versus-conservative options are explained in detail to the patient's relatives
How it's performed
- The patient is brought to the surgical area; general anesthesia is used in acute/severe cases, and local anesthesia/sedation may be used in selected chronic cases
- The scalp is shaved and sterilized, and the surgical area over the hematoma is draped
- In chronic subdural hematoma, one or two burr-holes (about 1-2 cm in diameter) are usually opened, the hematoma is irrigated, and a drainage catheter is placed
- In acute, thick, or clot-containing hematomas, a craniotomy (opening a wider piece of bone) is performed to evacuate the clot and control the bleeding source
- The subdural space is irrigated with saline and air is removed to allow brain re-expansion
- After the operation, the bone flap is replaced, the dura and skin layers are closed; a closed drainage system may be kept for 1-2 days if needed
Post-procedure
- Neurological examination and follow-up CT in the intensive care unit during the first 24-72 hours
- Removal of the drainage catheter is decided based on clinical and imaging findings (usually 24-48 hours)
- Hospitalization averages 3-7 days; level of consciousness, motor strength, and headache are monitored
- When to restart anticoagulant therapy is individualized by the team
- Clinical follow-up at 1, 4, and 12 weeks with imaging if needed; monitoring for recurrence (re-accumulation)
Risks
- Re-accumulation of the hematoma (especially 5-15% in chronic cases)
- Wound or intracranial infection (meningitis, empyema)
- Seizures (especially after acute hematoma and craniotomy)
- Brain edema, new neurological deficit, or stroke
- Systemic risks related to anesthesia and major surgery (especially in elderly patients with comorbidities)
FAQ
What is the difference between acute and chronic subdural hematoma?
Acute hematoma usually develops within hours of severe trauma, with fresh and dense blood, and surgery is performed urgently. Chronic hematoma develops over weeks from liquefied blood and more often presents in elderly patients with headache, imbalance, and forgetfulness.
Is surgery necessary for every subdural hematoma?
No. In small, asymptomatic, or minimally symptomatic hematomas, close imaging and clinical follow-up may be sufficient. Surgery is decided according to the size and progression of the hematoma and the patient's neurological status.
What is the difference between burr-hole drainage and craniotomy?
Burr-hole involves making a small opening in the skull to irrigate and drain, and is preferred in liquefied chronic hematomas. Craniotomy is a more extensive surgery in which a wider piece of bone is removed, used in acute, clotted, or actively bleeding cases.
How long does recovery take?
Hospitalization is generally 3-7 days. Full recovery occurs over weeks to months depending on the patient's age, comorbidities, and the impact of the hematoma on the brain. Close follow-up is important in elderly patients due to recurrence and fall risk.
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