1st order.
Depending on the findings, surgical therapy may be required. This is especially true for space-occupying, intracranial (“localized within the skull“) injuries.
For epidural hematoma (EDH), a surgical indication exists for:
- Focal neurologic deficits
- GCS* ≤ 8
- Space-occupying EDH with the following radiological characteristics:
- Width of the EDH > 15 mm
- Volume of the EDH > 30 cm3
- Center line displacement > 5 mm
* Glasgow Coma Scale (GCS) or Glasgow Coma Scale (scale for estimating a disorder of consciousness).
In the case of a subdural hematoma (SDH; hematoma) under (lat. sub) the meninges between the dura mater and arachnoid), which is very small (thickness: < 10 mm) and the patient has only mild or no symptoms, conservative therapy with corticosteroids (oral dexamethasone for two to three weeks) is sufficient. Thorough observation of the patient is necessary during treatment. Surgery is indicated for:
- Symptomatic hemorrhage
- Space-occupying chronic SDH with the following radiological characteristics:
- Width of the chronic SDH > 10 mm
- Midline shift > 5 mm
If the symptoms worsen, a trepanation (French: trépan drill; here. Drill hole trepanation) is required. In this case, a mini drill hole (about 5 mm) is sufficient in many patients; only with pronounced hematomas, several 12 mm holes are required.
In the case of space-occupying intracranial injuries (here intracranial hemorrhage, ICB), urgent surgery is required (trepanation). In neurosurgery, trepanation is referred to as craniotomy. This is the surgical opening of the skull (lat. cranium), which is performed to perform a surgical intervention inside the skull and/or to reduce intracranial pressure (intracranial pressure, i.e. the (intracranial) cerebrospinal fluid pressure prevailing inside the skull = decompression craniectomy. If the craniotomy serves solely to reduce intracranial pressure, it is also referred to as a decompression strep (synonym: decompression craniectomy).There is an indication for surgery in:
- Pathologic increase in intracranial pressure (ICP) despite maximal drug therapy.
- Space-occupying ICB with the following radiologic characteristics:
- Frontal or temporal ICB > 20 cm3 with GCS 6-8.
- Midline displacement > 5 mm
- ICB > 50 cm3 independent of the GCS
Further notes
- Craniectomy to relieve elevated intracranial pressure halved mortality in patients with severe traumatic brain injury (TBI) compared with continued medical therapy (48.9% versus 26.9%).The outcome was as follows (craniectomy versus medical therapy):
- At six months for severe brain injury in a vegetative state (apallic syndrome) (8.5% versus 2.1%).
- Depended on home care (21.9% versus 14.4%).
- Coped with their disabilities at home alone (15.4%versus 8.0%)
- Were moderately disabled (15.4%versus 8.0%).
- A good recovery ( 4.0% versus 6.9%).
- After 12 months, patients who were considered rehabilitated in good condition (9.8% versus 8.4%)
