Tubagus Firman H

01071190124

LO week 2.2
1. Type of brain herniation and its clinical features
2. Surgery indication for intracranial hematoma

Treatment of epidural hematoma The surgical procedure consists of placement of burr holes in a truly
emergency situation in the ED or at the bedside or, preferably a craniotomy, drainage of the hematoma, and
identification and ligation of the bleeding vessel. The operative results are excellent except in cases with
extended fractures and laceration of the dural venous sinuses, in which the epi- dural hematoma may be bilateral
rather than unilateral. If coma, bilateral Babinski signs, spasticity, or decerebrate rigidity supervene before
operation, it usually means that displacement of central structures and compression of the midbrain have already
occurred; prognosis is then poor, but a few patients do well if surgery is not greatly delayed. Small epidural
hemorrhages can be followed by serial CT scanning and will be seen to enlarge gradually for a week or two and
then be absorbed. There is controversy about the benefit of removing these smaller clots in a patient who has no
symptoms or signs; with sequential clinical and imaging surveillance, can be left alone.
Treatment of subdural hematoma In most cases of acute hematoma it is sufficient to place burr holes and
evacuate the clot before coma has developed. Treatment of larger hematomas, particularly after several hours
have passed and the blood has clotted, consists of craniotomy to permit control of the bleeding and removal of
the clot. As one would expect, the interval between loss of consciousness and the surgical drainage of the clot is
perhaps the most important determinant of outcome in serious cases. Thin, crescentic clots can be observed and
followed over several weeks and surgery undertaken only if focal signs or indications of increasing ICP arise
(headache, vomiting, and bradycardia). Small subdural hematomas causing no symptoms and followed by CT
scans will self-absorb, leav- ing only a deep yellow, sometimes calcified membrane attached to the inner dural
surface. If the acute clot is too small to explain the coma or other symptoms, there is probably extensive
contusion of the cerebrum or another lesion.

To remove more chronic hematomas, a craniotomy must be performed and an attempt made to strip the
membranes that surround the clot. This is said to dimin- ish the likelihood of reaccumulation of fluid but it is not
always successful. Other causes of operative failure are postoperative swelling of the compressed hemisphere or
failure of the hemisphere to expand after removal of a large clot. The difficulty of managing these patients
surgically should not be underestimated. Elderly patients may be slow to recover after removal of the chronic
hematoma or may have a prolonged period of confusion. Postoperative expansion of the brain can be followed
by serial CT scans and may take weeks. Small, asymptomatic chronic collec- tions are usually left alone and
followed serially by clinical and CT examination, first at several week and then longer intervals.

Although no longer a common practice, the administration of glucocorticoids was an alternative to surgical
removal of subacute and chronic subdural hematomas in patients with minor symptoms or with
contraindications to surgery. This approach, reviewed by Bender and Christoff decades ago, has not been
studied systematically but has been successful in a few of our patients (of course, they may have improved
independent of the steroids).

 tindakan bedah direkomendasikan untuk evakuasi EpiDH dengan volume >30ml berapapun
GCS pasien. Juga pada EDH akut dengan GCS <8 dengan pupil anisokor.

 tindakan bedah direkomendasikan untuk SubDH akut dengan tebal >10mm atau MLS >5mm
berapapun GCS pasien. Tindakan bedah juga direkomendasikan pada pasien dengan GCS <8
atau GCS turun 2 poin dibandingkan saat pasien datang, dan atau pasien dengan pupil
asimetris dan dilatasi, dan atau TIK >20mmHg.

 indikasi tindakan bedah pada ICH belum terlalu jelas. Beberapa sumber menyebutkan
evakuasi ICH pada volume >50ml, atau GCS 6-8 pada pasien dgn ICH di temporal atau frontal
volume >20ml dengan MLS >5mm dan atau kompresi sisterna pada CT Scan.

 Pemasangan ICP Monitor dilakukan pada pasien COB (GCS 3-8 setelah proses resusitasi)
dengan CT-Scan kepala abnormal (hematoma, contusio, edema serebri atau penyempitan
sisterna basalis). ICP monitor juga dipasang pada pasien COB dengan CT-Scan kepala normal
jika didapatkan 2 atau lebih 3 hal ini yaitu :

- Usia > 40 tahun

- TDS < 90 mmHg

- Postural bilateral atau unilateral