Surgical issues in the management of head-injured patients

This chapter reviews the indications for surgical intervention and operative nuances that may facilitate neurosurgical procedures. This includes discussion on the surgical management of patients with traumatic intracranial haematomas, depressed skull fractures, the placement of external ventricular drains and the application of decompressive craniectomy. Traumatic intracranial haematomas. Acute traumatic intracranial haematomas occur in the extradural space, the subdural space or directly into the parenchyma. The latter are often associated with haemorrhagic cerebral contusions. Although haematomas are frequently apparent within the first few hours after trauma, delayed presentation is well recognized and may present with deterioration in level of consciousness or elevation of intracranial pressure. After identifying an intracranial haematoma, a number of factors are considered. Each of these influences the patient's functional outcome as discussed below (Fig. 17.1). Age and pre-existing medical conditions. The incidence of extradural haematomas peaks in the second decade of life and is rare in patients older than 50 years of age. Within this population group the probability of a good outcome decreases with increasing patient age. Increasing age is also a strong independent variable associated with poor outcome in both acute subdural haematoma and intraparenchymal haematoma patient groups. In patients with acute subdural haematoma aged 18–30 years with GCS < 10 the mortality is < 25% at 2–3 months follow-up compared to 75% in older patients (>50yr). In patients > 65 years and especially in the >75yrs age group, the mortality increases exponentially and the chance of survival with good functional outcome is virtually zero. Evacuation of acute subdural haematomas in this latter age group is therefore probably not justified except in exceptional circumstances.