Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury
United States Department of Defense
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A critical step in the management of closed injuries is the recognition of which patients require operation for evacuation of intracerebral hematomas that can cause, or are likely to cause, neurological deterioration. Recognition of the presence of hematomas may have to be made solely on the basis of deteriorating neurological status if intracranial pressure (ICP) monitoring and CT scanning are unavailable. The presence of fractures across venous channels or sinuses, the site of intracranial fragments, or a tangential wound of the skull may indicate the presence and location of an intracranial hematoma. Tangential wounds produced by high-velocity missiles should be evaluated carefully, as there is often extensive brain injury under the site of skull impact. If a compound depressed fracture has been produced by a tangential wound, a craniectomy should be performed and the dura opened to inspect for subdural or intracerebral hematoma.
If the presence of a hematoma is suspected, radiographic confirmation can be obtained by CT, cerebral arteriography, or ventriculography, Useful information can be provided by even the most simple form of arteriography, obtained by puncture of the common cartoid artery with a 18 or 20 gauge needle, injection of 10 cc of low concentration radiopaque contrast over 1-2 seconds, and exposure of a single AP X-ray film of the head. Ventricular puncture and injection of 5 cc of air can also be used to demonstrate shift of the midline of the brain.
Intracranial hematomas that produce more than a 5 mm shift of the midline or similar depression of the cortical or cerebellar surface should be evacuated, as such hematomas are capable of producing neurological deterioration. Evacuation of acute subdural and epidural hematomas will require a craniotomy. A large fronto-temporal-parietal flap can be elevated quickly and provides good exposure of the cerebral convexity. If exploratory twist-drill holes or burr holes are made prior to a craniotomy, aligning the skin incisions should be done so that they can be extended into a craniotomy incision. The frontal burr hole is placed at the midpupillary line and 1 cm anterior to the coronal suture; the temporal hole is made at the pterion (junction. of the frontal, parietal, temporal squamosal, and sphenoidal bones).
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