Intracerebral Haematoma Requiring Neurosurgery

In the traumatic setting, intracerebral haematoma is focal accumulation of blood within brain parenchyma caused by disruption of intraparenchymal vessels.

It overlaps biologically with haemorrhagic cerebral contusion but usually refers to a more discrete mass lesion.

Common locations include:

• Frontal lobe
• Temporal lobe
• Deep white matter
• Basal ganglia after high energy shear injury

The operative question is not the presence of blood alone. Surgery is required when the haematoma produces neurological deterioration, intracranial hypertension or dangerous mass effect.

Features depend on location.

Presentation can include:

• Reduced consciousness
• Hemiparesis
• Aphasia
• Seizure
• Behavioural change
• Pupillary asymmetry
• Progressive intracranial hypertension

A patient who initially appears neurologically stable can deteriorate as the haematoma enlarges or surrounding oedema increases.

Noncontrast CT: define:

• Volume
• Location
• Midline shift
• Cistern compression
• Intraventricular extension
• Associated contusions
• Acute SDH

Repeat CT with any deterioration.

MRI is useful later when traumatic vascular or axonal pathology remains uncertain.

CT angiography should be considered when the haemorrhage location or mechanism suggests:

• Traumatic pseudoaneurysm
• Vascular malformation
• Spontaneous haemorrhage preceding trauma

Observation

Nonoperative management is appropriate when:

• Neurological status is stable
• ICP is controlled
• Lesion is relatively small
• No significant mass effect exists
• Serial CT and close monitoring are available

Operative indications

Operate for:

• Progressive neurological deterioration attributable to the lesion
• Medically refractory intracranial hypertension
• Significant mass effect

For frontal or temporal traumatic parenchymal lesions:

GCS 6 to 8 plus volume greater than 20 cm³

with:

• Midline shift at least 5 mm

or

• Basal cistern compression

is a strong operative indication.

Any traumatic parenchymal mass lesion larger than approximately 50 cm³ should generally be evacuated.

Procedure

Perform craniotomy and evacuate the haematoma.

Aim to:

• Relieve mass effect
• Achieve haemostasis
• Preserve surrounding viable cortex

If severe swelling persists:

• Enlarge decompression appropriately
• Perform duraplasty
• Leave the bone flap off where replacement would recreate dangerous ICP

Posterior fossa traumatic haematomas with brainstem compression, fourth ventricular distortion or obstructive hydrocephalus require particularly urgent evacuation because deterioration can be rapid.