Simple bedside technique for evacuating chronic subdural hematomas Technical note

ROBERTO A. NEGRON, M.D., GILBERTOTIRADO, M.D., AND ClgSAR ZAPATER, M.D.

Section of Neurological Surgery, School of Medicine, University of Puerto Rico, Halo Rey, Puerto Rico

The authors describe a simple spinal needle trephination technique found to be effective in the treatment of patients with chronic subdural hematomas. KEY WORDS

9 needle trephination

OR years we have drained chronic subdural hematomas by a single skull trephination. Thorough evacuation of all hematomafluid is not possible this way, but almost alI our patients have done well, without recurrences. We have concluded that whatever fluid was left has been absorbed. The spontaneous resolution of subdural hematomas has been described by several authors.1 a,5,8 Dr. Calvin Early, then of the National Institute of Health, Bethesda, Maryland,' taught us a simple method of penetrating the intracranial cavity with an 18gauge spinal needle bent at right angles for performing ventriculography? ,7 On the basis of this experience, we decided to employ this technique in the treatment of chronic subdural hematomas. We have since found that needle trephination is an effective means for evacuating chronic subdural hematomas.

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J. Neurosurg. / Volume 42 / May, 1975

9 chronicsubdural hematoma

Technique Once the diagnosis of chronic subdural hematoma is made, the patient's head is shaved and surgically prepared. Trephination is ,performed over the point of maximum displacement as indicated by angiography, with an 18-gauge spinal needle bent at right angles to provide a good grip. The cranium is perforated with back and forth twisting movements. Sometimes two needles may be required because of excessive bending of the tip. Once the skull is penetrated the perforating needle is removed and a fresh 18gauge needle is inserted into the subdural space. The hematoma is slowly aspirated while the patient's vital signs and neurological status are closely observed. As much as 100 cc of fluid has been removed from one side (185 cc from both sides) without untoward reactions. 609

R. A. Negr6n, G. q'irado and C. Zapater

FIG. 1. Case 1. Left." Right carotid arteriogram reveals large extracerebral collection with marked midline shift. Right: Repeat angiogram 16 days after needle trephination shows mild midline shift with no subdural collection.

FIG. 2. Case 2. Left." Right carotid angiogram shows chronic subdural hematoma. Right." Repea anglogram 17 days after needle trephination shows hematoma resolved. 6]0

J. Neurosurg. / Volume 42 / May, 197.

Evacuating chronic subdural hematomas Summary of Cases

Discussion

Five cases of subdural hematoma have Although this is a small number of been cured with this procedure. The two patients, we can draw some conclusions from following cases are examples. these cases. Evacuation of chronic subdural hematomas with spinal needle trephination Case 1 appears to be a safe, simple procedure that This 30-year-old man, a chronic alcoholic can be done at the bedside with no more with a history of multiple head trauma, was special equipment than a few 18-gauge spinal found unconscious. On admission he needles and a syringe. This technique appears responded only to painful stimuli; he dis- to have the following advantages: played right Chaddock and Hoffmann's signs, 1. It may be as good as standard burr holes but no focal neurological signs. Right carotid in the evacuation of chronic subdural arteriography revealed a large extracerebral hematomas. collection with marked midline shift (Fig. 1 2. It may be life-saving in patients whose left). Right temporal needle trephination was condition is rapidly deteriorating or who done, and 80 cc of dark thick fluid were are remote from neurosurgical facilities. aspirated. A repeat angiography 16 days later 3. Non-neurosurgeons could use this revealed a mild midline shift with no subdural technique as an emergency procedure collection (Fig. 1 right). Two days after that until the patient is able to reach a the patient was discharged alert, well orineurosurgeon. ented, and ambulatory, with no focal deficit. 4. It could be used as a diagnostic Three months after trephination the patient therapeutic technique in the elderly, was neurologically and mentally normal. hypertensive patient in whom angiography could constitute a risk. Case 2 This 51-year-old man was found unconscious and admitted to the hospital. He References gradually improved and was discharged. Thirteen days later he became semistuporous 1. Ambrosetto C: Post traumatic subdural hematoma. Further observations on nonand responded to verbal stimuli only after surgical treatment. Areh Neurol 6:287-292, much physical stimulation; on readmission he 1962 had a left Babinski sign but showed no other 2. Bender MB: Recovery from subdural focal deficit. Right carotid angiography hematoma without surgery. J Mount Sinai revealed a chronic subdural hematoma (Fig. 2 Hosp 27:52-58, 1960 left). Right frontotemporal and parietooc- 3. Chokroverty S, Mayo CM: Spontaneous cipital needle trephinations were done and 60 resolution of subdural hematoma. Dis Nerv cc of old fluid blood evacuated. Repeat Syst 29:704, 1968 angiography 17 days later revealed that the 4. Early C: Personal communication, 1969 hematoma had resolved (Fig. 2 right). Eigh- 5. Obach R, Sol6-Llenas J, Planas M, et al: (Subdural hematoma with spontaneous remission). teen days after evacuation the patient was disRev Ciin Esp 112:481-484, 1969 (Spa) charged alert, well oriented, and ambulatory, 6. Rand BO, Ward AA Jr, White LE Jr: The use with no neurological deficit. of the twist drill to evaluate head trauma. J Neurosurg 25:410-415, 1966 Comment 7. Rifkinson M, Alvarez J, Borras PJ, et al: A In two cases needle trephination proved insimple method for ventriculography. J effective in permanent control of subdural Neurosurg 38:393-394, 1973 hematoma disease. In one, standard trephina- 8. Suzuki J, Takaku A: Nonsurgical treatment of tion had to be done after needle trephination chronic subdural hematoma. J Neurosurg had failed; this was also ineffective, and only 33:548-553, 1970 stripping of membranes could control the disease. In the other case the patient died of a pulmonary embolus while under treatment; Address reprint requests to: Roberto A. Negron, autopsy revealed subtemporal and subfrontal M.D., Section of Neurological Surgery, School of collections that probably would have been Medicine, University of Puerto Rico, Hato Rey, missed with standard trephines as well. Puerto Rico.

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Simple bedside technique for evacuating chronic subdural hematomas. Technical note.

The authors describe a simple spinal needle trephination technique found to be effective in the treatment of patients with chronic subdural hematomas...
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