|Year : 2019 | Volume
| Issue : 1 | Page : 91-93
Craniotomy and Evacuation at Remote Island Hospital; Challenges and Way Ahead
Bharat K Jani1, SGS Datta2
1 Classified Specialist Surgery, INHS Dhanvantari, Port Blair, Andaman and Nicobar Islands, Mumbai, Maharashtra, India
2 Senior Advisor Surgery and Neurosurgery, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||05-Apr-2018|
|Date of Acceptance||19-Oct-2018|
|Date of Web Publication||19-Jun-2019|
Surg Cdr Bharat K Jani
INHS Dhanvantari, Minnie Bay, Port Blair - 744102, Andaman and Nicobar Islands
Source of Support: None, Conflict of Interest: None
We herein report the management of a case of acute-on-chronic subdural hematoma by emergency craniotomy at mid-zonal hospital with basic surgical facilities. The timely intervention has made significant difference in patient outcome. A 72-year-old male was on antiplatelet agents, presented with status epilepticus, and also had multiple comorbidities. We faced challenges of specialist consultation, medical evacuation of an intubated case, neurosurgery intensive care, and availability of blood products and intensivists at place like Andaman and Nicobar islands where connectivity remains a challenge. Casualty evacuation and transport of critical patients by air are a major exercise and are not possible in certain situations. Moreover, it is potentially detrimental to the life of a patient during air evacuation due to changes in the atmospheric pressure. In such adverse situations, aggressive surgical intervention at small centers can make significant difference in the outcome of patient.
Keywords: Craniotomy and evacuation, duraplasty, subdural hematoma
|How to cite this article:|
Jani BK, Datta S. Craniotomy and Evacuation at Remote Island Hospital; Challenges and Way Ahead. J Mar Med Soc 2019;21:91-3
| Introduction|| |
Subdural hematoma (SDH) is a collection of blood in the potential space between the arachnoid and the dura and is formed when venous, or rarely arterial, blood dissects between the dura and the arachnoid. It is labeled as chronic when the presentation is 2–3 weeks or longer after the initiating injury. Rupture of a bridging vein in an atrophic brain appears to be an important predisposition as most patients are elderly people or chronic alcoholics. In certain situations, immediate surgical intervention makes significant difference in the patient outcome, especially in places where neither the neurosurgical center nor medical evacuation (medevac) facilities are available. There is also a logistic issue in transporting the patients in intubated and ventilated conditions.
Management of such cases in the remote places remains a challenge in itself. Although neurosurgical evaluation and intervention is the standard of care, the same is not available at remote places. Air evacuation has important intracranial issues due to effects of changes in the atmospheric pressure. Decompressive craniotomy remains a practical and very important tool at the hands of a general surgeon in the periphery. However, postoperative support in an advanced intensive care unit (ICU) setup, ready availability of blood products as required, and supportive care of intensivists is hard to come by in such places and is also a challenge in the overall management of these cases.
| Case Report|| |
A 72-year-old male, known case of Type-II diabetes mellitus, primary hypertension, and hypothyroidism with poor compliance to medication, presented with status epilepticus. He presented with a history of seizures for 2 h, vomiting, and altered sensorium, and there was no reliable history of trauma. After resuscitation and stabilization at emergency room, his Glasgow coma score (GCS) was E1V3M3, the pupils were mid-dilated (left > right), sluggishly reacting to light, and his blood pressure was 100/60 mmHg. Urgent noncontrast computed tomography (NCCT) head [Figure 1] showed a large hypodense left parieto-temporal SDH with midline shift of 12 mm and impending herniation and mass effect. Respiratory findings were suggestive of aspiration.
|Figure 1: Preoperative noncontrast computed tomography head suggesting large temporoparietal subdural hematoma|
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He was electively intubated and was taken up for immediate burr hole craniotomy under general anesthesia and later converted to craniotomy for complete removal of clot. Brain regained to its normal status on the table itself – it came to surface and was pulsating well. Lax duraplasty was done using pericranium, to retain adequate space for brain to expand; bone flap was loosely placed over and incision closed over a subgaleal suction drain. The patient was electively ventilated postsurgery in view of compromised lungs.
Postoperatively, repeat NCCT brain [Figure 2] showed near-complete evacuation of clot and restoration of midline shift status.
|Figure 2: Postoperative noncontrast computed tomography head suggesting large temporoparietal subdural hematoma|
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Postoperative recovery was good [Table 1]. Supportive measures such as bowel clearance, control of blood sugars, nursing support, care of lungs, and early restoration of radiotherapy feed helped in early good recovery. He was extubated on the 5th day once the lungs recovered satisfactorily. Postextubation, his GCS improved to 14/15 (E4V4M6). He was started on oral feeds gradually.
| Discussion|| |
The epidemiology and presentation of acute and chronic SDH are completely different. A specific history of trauma with short duration illness is a key feature in acute case. In chronic SDH, the patient is often elderly, and on anticoagulant/antiplatelet medications usually presents with a history of recent fall. Repeated trivial falls causing cycles of accumulation of clot, spontaneous stoppage due to tamponade effect and osmotic expansion due to clot regression produces symptoms and is a reason for delayed presentation. Imaging reveals diffuse hypodensity overlying the brain surface. Recent recurrent bleeding may be isodense or hyperdense, and mixed density can indicate an acute-on-chronic SDH. Urgency is dictated by the clinical condition of the patient. If clinically stable, the patient is optimized for surgical intervention and can be delayed for a few days. In periphery, generally accepted procedure is twist drill craniostomy or burr hole twist drill craniotomy, which can be a bedside procedure and gives excellent results. Burr hole evacuation can be done under local anesthesia at specialized centers (especially in elderly patients who present a substantial anesthetic risk). Occasionally, acute-on-chronic bleeds with residual solid clot or septations require a craniotomy for adequate clot evacuation. However, in cases with mass effect and significant midline shift, status epilepticus, the brain tends to swell again once the compression is removed. It requires space to expand. Here comes the role of decompressive craniotomy. Decompressive craniotomy involves removal of a portion of the skull vault and opening of the underlying dura [Figure 3] so that brain swelling can occur without the pressure increases predicted by the Monro–Kellie doctrine.
|Figure 3: Intraoperative image of decompressive craniotomy at remote island hospital|
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One of the main challenges, in this case, was to get him to a neurosurgery center. Services of a neurosurgeon are not available in this remote island. Nearest mainland is at 1500 km with air time of minimum 140 min. In the absence of signs of herniation, sedation can be used when required for safe and efficient transport of the patient. Even in the stable case, it is recommended to reduce the transport time as it is often accompanied by secondary insults (e.g. hypoxia or hypotension). Pharmacologic paralysis, which is very much required during transport of the patient to higher center, which interferes with neurologic examination, should be used only if sedation alone is inadequate for safe and effective transport and resuscitation. Prophylactic hyperventilation, which may exacerbate early ischemia, is not recommended for these patients.
Rapid evacuation of mass lesions decreases intracranial pressure (ICP) and consequently improves cerebral perfusion pressure (CPP) and cerebral blood flow; reversal of ischemia soon after removal of an SDH has been documented. With the altered sensorium, emergency evacuation of SDH performed within 4 h of injury has been shown to result in a better outcome. It is also important to note that the procedures and protocol of aeromedical transport are very specific, cumbersome, and lengthy.
A GCS of 8 or lower after resuscitation is an indication for admission to a neurosurgical ICU. The focus of ICU management is the prevention of secondary injury and maintenance of adequate cerebral oxygenation by optimal cerebral oxygenation, CPP, hemoglobin concentration, and oxygen saturation. Although ICP monitoring is an important parameter for neuromonitoring, it is hardly available at remote centers. ICP monitoring is indicated in patients with a GCS of 3–7 after resuscitation and in selected patients with a GCS of 8–12 and an abnormal CT scan at the time of admission.
| Conclusion|| |
Neurological emergencies face a unique challenge of surgical expertise along with postoperative intensive care for better patient outcome. Urgent evaluation and immediate intervention are keys to positive outcome. Medevac by air in such cases is like walking on a tightrope and best be avoided if proper facilities such as dedicated air ambulance are not available. Basic surgical intervention in this case is craniotomy and evacuation and should be attempted as a life-saving measure where indications exist.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]