A hematoma evacuation procedure involves the surgical removal of a localized collection of blood outside of blood vessels, known as a hematoma. This occurs when a blood vessel ruptures, causing blood to pool in a confined space. When this pooled blood exerts pressure on surrounding tissues or organs, it can cause significant problems, requiring drainage or removal.
Medical Indications for Hematoma Evacuation
The decision to perform a hematoma evacuation hinges on several factors, including the hematoma’s location, its size, and how quickly it is growing. Hematomas within the skull, such as subdural or epidural hematomas, are concerning due to limited space, which can compress brain tissue. A subdural hematoma, which forms between the brain and its outer protective layer (dura mater), often results from trauma that tears bridging veins and can develop slowly over hours or days. An epidural hematoma, located between the skull and the dura mater, typically arises from arterial bleeding, often linked to a skull fracture, and can progress rapidly.
Symptoms signaling a need for urgent intervention include severe headaches, confusion, and other neurological deficits such as weakness, speech difficulties, or seizures. A sudden loss of consciousness or a deteriorating neurological status can also indicate that the hematoma is placing dangerous pressure on the brain. For instance, an acute subdural hematoma thicker than 5 mm or an epidural hematoma with a volume over 30 mL, especially with neurological signs like lethargy or a midline shift, may require surgery. Smaller hematomas with minimal or no symptoms may be monitored with serial imaging to see if they resolve.
Surgical Evacuation Techniques
The method chosen for hematoma evacuation depends on characteristics like the hematoma’s consistency (whether it is liquid or clotted) and its precise location. Neurosurgeons employ various techniques to address these blood collections, each tailored to the clinical situation. The goal is always to remove the accumulated blood while minimizing damage to surrounding tissues.
One less invasive approach is the burr hole procedure, primarily used for draining chronic subdural hematomas often developing days or weeks after injury. During this procedure, a surgeon drills one or more small holes, typically about the size of a dime, into the skull. Through these openings, a flexible rubber tube drains the liquid or semi-liquid blood. A drain may remain for a few days to prevent re-accumulation. This method is often performed under general anesthesia, though local anesthesia can also be an option.
A more extensive procedure is a craniotomy, generally used for acute subdural hematomas or larger, clotted collections. This involves temporarily removing a section of the skull, creating a “bone flap” for direct access to the hematoma. After a scalp incision, the surgeon drills small holes and uses a saw to connect them, freeing a piece of bone. The hematoma is then carefully removed, often using suction and irrigation.
Once the blood clot is cleared and bleeding stopped, the bone flap is typically reattached using plates and screws, and the scalp incision is closed. If severe brain swelling occurs, the bone flap may be left out temporarily and reattached later.
Minimally invasive endoscopic evacuation is another technique using a small camera and specialized instruments through a small incision, often a burr hole or a small craniotomy. This method allows the surgeon to visualize the hematoma cavity on a screen while aspirating blood clots with suction. Continuous irrigation with fluid can help confirm bleeding points, controlled with endoscopic bipolar cautery. This technique is advantageous for certain deep-seated hematomas, such as those in the cerebellum or within the brain’s ventricles, as it can reduce operation time and improve clot removal.
Post-Procedure Care and Recovery
Following a hematoma evacuation, patients typically spend time in an intensive care unit (ICU) for close monitoring. During this immediate postoperative period, medical staff closely observe vital signs, neurological status, and intracranial pressure to prevent further brain injury. If drains were placed during surgery, they are usually removed within one to two days after the procedure. The length of the hospital stay varies, often ranging from several days to a few weeks, depending on the initial injury’s severity, the hematoma’s location, and the patient’s overall recovery.
Once stable, patients may be transferred to a general ward before discharge home or to a rehabilitation facility. The longer-term recovery process often involves rehabilitation therapies to help regain lost functions. Physical therapy can assist with mobility and strength, occupational therapy focuses on daily living activities, and speech therapy addresses any communication or swallowing difficulties. Patients are generally advised to avoid activities that could cause head trauma and may be restricted from driving for a period. While rare, potential complications after discharge include infection at the surgical site, re-bleeding, or hematoma recurrence, potentially requiring further surgery.