Advances in both neurosurgery and endovascular therapy have resulted in increased surgical and interventional treatment options for patients with neurologic disorders. The postoperative disposition of these patients varies per institution and per critical care bed availability. In some instances, these patients may remain in the PACU for close observation for an extended period. The perianesthesia nurse must possess the knowledge and skills for both routine perianesthesia nursing care as well as the knowledge and understanding of the complexities of the nervous system and of neurosurgical and neurointerventional procedures in order to assess, provide care for, and comprehensively evaluate these patients. Meticulous perianesthesia nursing care must be provided to the neurosurgical patient, including preoperative baseline neurological assessment and patient teaching, postoperative patient assessment and management, and attentive discharge teaching and patient disposition. Given the critical nature of neurosurgical procedures, there is risk of alteration in cognitive function, level of consciousness, permanent or temporary disability, pain, or even loss of life. Timely identification and intervention are essential in the event of postoperative complications to mitigate the risk of death or permanent disability.
Advances in both neurosurgery and endovascular therapy have resulted in increased surgical and interventional treatment options for patients with neurologic disorders. The postoperative disposition of these patients varies per institution and per critical care bed availability. Some organizations require that neurosurgical critical care patients go directly to the postanesthesia care unit (PACU) before transferring to a critical care, neurologic critical care, or inpatient unit. In some instances, these patients may remain in the PACU for close observation for an extended period. The perianesthesia nurse must possess the knowledge and skills for both routine perianesthesia nursing care as well as the knowledge and understanding of the complexities of the nervous system and of neurosurgical and neurointerventional procedures in order to assess, provide care for, and comprehensively evaluate these patients. Meticulous perianesthesia nursing care must be provided to the neurosurgical patient, including preoperative baseline neurological assessment and patient teaching, postoperative patient assessment and management, and attentive discharge teaching and patient disposition. Given the critical nature of neurosurgical procedures, there is risk of alteration in cognitive function, level of consciousness, permanent or temporary disability, pain, or even loss of life. Timely identification and intervention are essential in the event of postoperative complications to mitigate the risk of death or permanent disability.
AtonyDecreased or absent muscle tone.
Babinski ReflexA reflex that is assessed as part of neurological testing to evaluate normal development in infants or neurologic abnormalities in adults. The Babinski reflex is a normal spinal reflex up to the age of 24 months, after which time it should disappear. The reflex is elicited with firm stroking of the lateral aspect of the sole of the foot. A positive or present Babinski response elicits dorsiflexion of the big toe with extension and fanning of the other toes. In adults and children over the age of 2, this is an abnormal finding and may be indicative of disorders of central nervous system function.
BaroreceptorA sensory nerve cell aggregate present in the wall of a blood vessel stimulated by changes in blood pressure.
Brain HerniationOccurs when one part of the brain moves beyond its normal border, resulting in ischemia and infarction if untreated.
Burr HoleA hole created in the skull with a special drill to evacuate a clot or hematoma; tissue biopsy; preparation for craniotomy.
Cerebral ContusionBruising of the surface of the brain; clinical effects vary depending on size of the injury and associated cerebral edema. Larger injuries may result in neurologic deficits, increased edema, and resultant increase in intracranial pressure.
Choroid PlexusPlexus of cells in the ventricles of the brain that produce most of the cerebrospinal fluid of the central nervous system.
ComplianceThe ability of the brain to yield when a pressure or force is applied.
ConcussionA change in brain function following an external force to the head; may be accompanied by brief loss of consciousness and/or transient retrograde amnesia. Diagnosis of a concussion is made by patient history and neurological examination.
CraniectomyRemoval of a portion of the skull without a replacement.
Craniocerebral Trauma/Traumatic Brain InjuryInjury to the skull, brain, or both that results in alternation in normal function and requires treatment.
CranioplastyRepair of the skull with replacement of a part of the cranium with a synthetic material.
CraniotomyA surgical opening of the skull.
CrepitusA crackling sound produced by the rubbing together of fractured bone fragments or by the presence of subcutaneous emphysema.
Cushing TriadPhysiologic nervous system response of elevated systolic blood pressure, bradycardia, and widening pulse pressure in the setting of increased intracranial pressure.
DecompensationThe failure of an organ (often the heart or the liver) to compensate for the functional overload resulting from a disease.
Diabetes InsipidusA metabolic disorder caused by injury or disease of the posterior lobe of the pituitary gland (the hypophysis).
Diffuse Axonal InjuryPrimary traumatic brain injury due to rotational acceleration-deceleration forces in which nerve fibers and small blood vessels are damaged due the shearing forces.
External Ventricular DrainageAlso known as a ventriculostomy. Catheter is inserted into a ventricle in the brain and attached to a collection system. Used to treat increased intracranial pressure by draining cerebrospinal fluid. A component of intracranial pressure monitoring.
Focal DeficitAny sign or symptom that indicates a specific or localized area of pathologic alteration.
Foramen of MonroChannel between the paired lateral ventricles in the brain and the third ventricle. Used as reference point for intracranial pressure monitoring.
HemiplegiaParalysis of one side of the body.
HistologicTypes of cells or tissues visualized under a microscope.
InfratentorialThe area below the tentorium that includes the brainstem, cerebellum, and posterior fossa.
LaminectomyExcision of the posterior arch of a vertebra to allow excision of a herniated nucleus pulposus.
Midline ShiftOccurs when the pressure inside the brain from bleeding or swelling of brain tissue is sufficient to push the brain off-center. Midline shift is associated with high intracranial pressure and requires immediate neurosurgical intervention if feasible.
Neurogenic ShockCardiovascular hypotension due to disruption of sympathetic function leaving parasympathetic function unopposed. Additional clinical signs of neurogenic shock include warm skin and bradycardia/bradyarrhythmia.
ParenchymaFunctional tissue of an organ.
Phrenic NucleusA group of nerve cells located in the spinal cord between the levels of C3 and C5. Damage to this area abolishes or alters the function of the phrenic nerve.
Pyramidal SignsSymptoms of dysfunction of the pyramidal tract including spastic paralysis, Babinski reflex, and increased deep tendon reflexes.
Spinal ShockA state that occurs after a spinal cord injury. All sensory, motor, and autonomic activities are lost below the level of the lesion and reflexes are absent. Paralysis is of a flaccid nature and includes the urinary bladder. Autonomic activity gradually resumes as spinal shock subsides. Flaccid paralysis may evolve into varying degrees of spastic paralysis, as evidenced by spasms of flexor or extensor muscle groups. The presence of autonomic activity also allows for episodes of autonomic hyper-reflexia.
Subarachnoid BlockThe injection of a local anesthetic into the subarachnoid space around the spinal cord.
SubluxationPartial or incomplete dislocation.
SupratentorialThe area above the tentorium that includes the cerebrum.
Tonoclonic MovementsTense muscular contractions that alternate rapidly with muscular relaxation.
Patients requiring neurosurgery or neurointerventional procedures often present with an acute, urgent, or even emergent alteration in neurologic function, evidenced by pain, numbness, loss of consciousness or change in level of consciousness, seizures, or traumatic injury. Thorough patient history and a comprehensive neurologic assessment is required in order to determine if dysfunction is present, to diagnose the etiology of the clinical presentation, and to identify the location of the disease within the nervous system. Major components of the neurological examination include assessing level of consciousness (LOC), mental status, cranial nerves, motor and sensory function, cerebellar system, and reflexes as clinically indicated.1,2
Several standardized neurological assessment tools are available and are frequently used. The American Spinal Injury Association (ASIA) developed a universal classification tool for spinal cord injury: the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), more commonly referred to as the ASIA scale (Fig. 38.1).The Glasgow Coma Scale (GCS) is a universally accepted scoring system used to assess the LOC of patients; it is most commonly used following a traumatic brain injury (Table 38.1). The 12 paired cranial nerves relay information between the brain and parts of the body and serve either or both motor and sensory function. Disorders of cranial nerves may be due to compression from lesions or vasculature, trauma, infectious processes, or may appear after some surgical procedures. Cranial nerve assessment is a component of both preoperative and postoperative neurologic assessment (Table 38.2). See also Fig. 10.5. Radiographic imaging is a key component of a diagnostic evaluation following any alternation in neurologic function (Box 38.1, Fig. 38.2).
•Assess patient allergies to contrast dye, shellfish.
•Routine post sedation/anesthesia care following moderate sedation or anesthesia as applicable.
•Frequent assessment of access site for bleeding or presence of a hematoma.
•Frequent vascular assessment (pulse check) of the affected limb. Assess pedal pulses for a femoral puncture approach and radial pulses for a brachial puncture. Bed rest is often required for 1 to 4 hours post procedure. An immobilizer is often applied to prevent the patient from bending the affected limb.
•A closure device is frequently used on the puncture site. Follow institutional policies and/or manufacturers recommendations for care.
•Frequent neurologic assessments including pupil assessment. The most common complication is ischemic stroke due to plaque rupture, air embolism, or vessel dissection.
•Allergic reaction to contrast dye or contrast-induced nephropathy may occur despite documented no previous allergies. Ensure adequate hydration to clear the contrast medium; monitor intake and output closely.
Modified from Bennet N. Diagnostics for patients with neurologic disorders. In: Hickey JV, Strayer AL, eds. The Clinical Practice of Neurological and Neurosurgical Nursing. 8th ed. Wolters Kluwer; 2019; Chernoff D, Stark, P. Principles of magnetic resonance imaging. In: Post TW, ed. UpToDate. UpToDate Inc.; 2021. www.uptodate.com. Accessed August 23, 2021; Singer RJ, Ogilvy CS, Rordorf G. Screening for intracranial aneurysm. In: Post TW, ed. UpToDate. UpToDate Inc.; 2021. www.uptodate.com. Accessed August 23, 2021; Windle PE. Neurological. In: Schick L, Wndle PE, eds. PeriAnesthesia Nursing Core Curriculum. Preprocedure, Phase and Phase II PACU Nursing. 4th ed. Elsevier; 2021:446–498.
An intracranial aneurysm (IA)3 is a blood-filled outpouching of the cerebral artery wall that develops as a result of weakening of the inner muscular layer (the intima) of a blood vessel (Fig. 38.3). Most IAs occur at bifurcations, where blood vessels divide. The majority arise within the circle of Willis. Aneurysms are described by their location, size, and shape, such as berry, or saccular in shape, or fusiform, a spindle-like shape that tapers at each end. Risk factors4 for aneurysm formation include congenital factors as well as hypertension, infection, trauma, advancing age, or smoking. Family history of aneurysm formation may also be a potential risk factor.
Aneurysms are usually asymptomatic and present no clinical problem to the patient unless rupture occurs.4 The patient may present with a minor headache, blurred vision, or cranial nerve palsy.3 Sometimes an aneurysm is identified during an evaluation for other medical conditions. However, the classic presentation of a subarachnoid hemorrhage (SAH) following IA rupture is a severe headache, described by the patients as the worst headache of their life.4 This is generally indicative of a sharp increase in intracranial pressure (ICP) and may be accompanied by nausea, vomiting, slurred speech, and loss of consciousness.5 A ruptured IA is a major cause of subarachnoid hemorrhage or hemorrhagic stroke and is associated with a high morbidity and mortality.5 Surgical clipping and endovascular coiling are the most common interventions for aneurysm treatment.6
Following the International Subarachnoid Aneurysm Trial (ISAT), coil embolization is now the recommended initial treatment for many IAs.4 Endovascular therapy is typically performed in interventional neuroradiology (NIR) suites, often with either monitored anesthesia care or a general endotracheal anesthetic. The latter is selected in situations requiring airway protection, prevention of patient movement during imaging and intervention(s), and to allow periods of temporary apnea as desired by the proceduralist. During coil embolization,6 vascular access is achieved most commonly via the femoral artery. A catheter is threaded into the cerebral vasculature and cerebral angiography is performed, creating a map for the proceduralist. A smaller catheter is then advanced into the neck of the aneurysm and platinum coils are deployed into the lumen of the aneurysm. A local thrombus forms around the coils, thus obliterating the aneurysm sacs to prevent future rupture or to halt further bleeding. Complications include thromboembolism, intraprocedural aneurysmal rupture, and reoccurrence of aneurysm formation.6
Surgical interventions include placement of titanium clips across the neck of the aneurysm. Surgical complications include new or worsened neurologic deficits, bleeding, or aneurysm rupture.6
Priorities of postintervention and postsurgical management are focused on prevention of rebleeding.6 Strict blood pressure control is essential and maintained per parameters ordered by the attending provider. Typical blood pressure parameters are to maintain systolic blood pressure less than 160 mm Hg or mean arterial pressure less than 110 mm Hg.4,5 Blood pressure measurements include noninvasive and/or invasive arterial measurements which allow for continuous dynamic pressure assessment. Calcium channel blockers such as nicardipine or clevidipine are commonly used for elevated blood pressures.6
Other postoperative complications include acute hydrocephalus, cerebral edema, seizure, delayed ischemic neurologic deficit, and/or cerebral vasospasm.7 Ongoing comprehensive neurological assessment is essential for early identification and treatment of complications to ensure the best patient outcome. Other procedure-specific nursing assessments include frequent vascular access site checks, accurate intake and output, and distal pulse assessment.
An intracranial arteriovenous malformation (AVM) is a vascular network that appears as a tangled mass of dilated vessels, creating an abnormal communication between the arterial and venous systems. AVMs are usually present at birth as the result of congenital abnormalities but may also have a delayed age of onset. There are two pathophysiologic characteristics related to AVMs. The abnormal vasculature predisposes the blood vessels to rupture and hemorrhage. There may also be impaired perfusion to the cerebral tissue adjacent to the AVM that presents clinically as slowly progressive neurological deficits.8
While many AVMs are relatively benign without complications, hemorrhage is the most common pathologic presentation of an AVM. Clinical presentations may include headache and/or seizures. Diagnostic procedures include computed tomography (CT), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or cerebral angiography. Treatment decisions are complex and include surgery, embolization, stereotactic radiosurgery, or a nonoperative conservative approach. Postprocedure and postoperative management focuses on meticulous neurological assessment and blood pressure monitoring. Mild hypotension may be desired to allow gradual changes in vascular flow in the brain tissue surrounding the AVM.8
A cerebrovascular accident (CVA) or stroke occurs when the blood supply to part of the brain is interrupted or reduced, thus preventing brain tissue from getting sufficient oxygen and nutrients. Permanent injury due to brain cellular death will result. Causes of a stroke include hemorrhage or ischemia due to arterial occlusion, an embolic event or inadequate vascular blood flow due to decreased perfusion pressure, or increased blood viscosity.9 Stroke is the fifth leading cause of death in the United States according to the Centers for Disease Control and Prevention.10 Approximately 80% of strokes are due to ischemic cerebral infarction and 20% due to brain hemorrhage.11 Risk factors for acute stroke include hypertension, atrial fibrillation, diabetes mellitus, cigarette smoking, and dyslipidemia.9,12 Transient brain ischemia (TIA) is a transient episode of neurologic dysfunction without evidence of an acute infarction following diagnostic imaging.
Clinical presentation of a TIA or stroke includes hemiparesis, dysarthria, dysphagia, diplopia, and motor or sensory weakness.11,12 The National Institutes of Health Stroke Scale (NIHSS) is a standardized stroke assessment tool that is used to assess and quantify stroke severity12 (Table 38.3). At timely diagnosis to provide appropriate care and management is imperative. Diagnostic procedures include a CT without contrast to ascertain ischemic versus hemorrhagic stroke.12 A CT scan with contrast may be performed to rule out the presence of lesions that may mimic a TIA. Further testing may be performed as needed for a conclusive diagnosis.
National Institutes of Health Stroke Scale (NIHSS)
The NIH Stroke Scale (NIHSS) is a 15-item neurologic examination used to evaluate the effect of an acute stroke. Total scores on the NIHSS range from 0 to 42, with higher values reflecting more severity.
Procedure for Use
A trained observer rates the patient’s ability to answer questions and perform activities. Ratings for each item are scored, and there is an allowance for untestable (UN) items. If an item is left untested, a detailed explanation must be clearly written on the form. Training can be completed free at www.nihstrokescale.org.
Level of consciousness
0 = Alert 1 = Not alert, but arousable by minor stimulation 2 = Not alert, requires repeated stimulation to get attention 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic
The primary treatment goal for patients suffering from an embolic stroke is prompt restoration of blood flow by removing the occlusive intracranial thrombus.11,13 Reperfusion treatment options for eligible patients include intravenous thrombolytic drug therapy and/or mechanical thrombectomy.11,13 Based on time last known well (TLKW), intravenous administration of alteplase or tPA may be indicated for up to 4.5 hours following symptom onset.11,13 Mechanical thrombectomy (MT) and intra-arterial thrombolysis are other treatment options available in NIR. Procedural sedation management for patients undergoing MT vary from local anesthesia to moderate sedation to anesthesia-provided monitored anesthesia care or general endotracheal anesthesia, depending on institutional guidelines, resources, and the patient’s clinical presentation. Anesthesia management may be requested for the patient unable to protect their airway; unable to lie still and/or follow commands; hemodynamically unstable or if tight blood pressure control is required with vasopressor therapy. See Evidence-Based Practice box.
The American Heart Association provides guidelines for managing patients early after experiencing an acute ischemic stroke. Current recommendations include door to CT imaging as best practice prior to a full initial patient assessment to rule out presence of intracranial hemorrhage. If no hemorrhage is present, medical management with intravenous thrombolytics is a treatment option for patients presenting with 4.5 hours since time last known well. Eligible patients should receive alteplase, a thrombolytic medication, in the fastest achievable onset-treatment time. Mechanical thrombectomy (MT) with stent retrieval devices has become a standard of care for eligible patients with large vessel obstruction. Eligibility criteria for MT include but are not limited to: prestroke-modified Rankin score of 0 to 1; acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset if having met thrombolytic treatment eligibility criteria; causative occlusion of the internal carotid artery or proximal middle cerebral artery; age ≥18 years; National Institutes of Health Stroke Scale (NIHSS) score of ≥6; and treatment can be initiated (groin puncture) within 6 hours of symptom onset.
Post MT procedure care locations may vary from critical care to PACUs. As such, perianesthesia nurses should have the knowledge and skills to care for patients who have received thrombolytic therapy and/or MT as well as familiarity with stroke assessment scales such as the NIHSS. Priorities of nursing care include assessment of airway patency, oxygenation and ventilation, hemodynamic stability with a focus on blood pressure parameters per provider orders, and neurologic status. Ongoing comprehensive neurologic assessment and knowledge of post thrombolytic/MT complications is essential.
From American Heart Association. Care of the patient with acute ischemic stroke (prehospital and acute phase of care): update to the 2009 comprehensive nursing care scientific statement. Stroke 2021;52(5):e164–e178.
Critical knowledge for perianesthesia nurses is that a stroke may occur perioperatively or while the patient is in the PACU. Certain surgical procedures such as a carotid endarterectomy pose an increased risk for perioperative ischemic events due to plaque disruption. In addition to routine vital signs, meticulous blood pressure assessment and adequate oxygenation must be evaluated to ensure cerebral perfusion. Baseline neurologic function should be assessed prior to surgery and a routine neurologic assessment performed for all patients upon admission to the PACU and periodically thereafter to include LOC, mental status, and motor strength and movement. Timely provider notification is crucial to ensure early diagnosis and intervention.
An estimated 84,170 new cases of primary malignant and nonmalignant brain and other central nervous system tumors are expected to be diagnosed in the United States in 2021.14 Brain tumors may be primary or the more common, secondary metastatic lesions that have spread to the brain from another location. The clinical presentation of a brain tumor depends on tumor location, rate of growth, and impact on ICP. Signs and symptoms vary and include headaches, nausea and vomiting, confusion, changes in LOC, and/or seizures. Diagnostic evaluation includes neuroimaging with either or both CT and MRI. A brain biopsy may be performed if the lesion is surgically accessible. Treatment is based on histologic findings and includes surgery, radiation, and/or chemotherapy.
Hydrocephalus is a chronic clinical syndrome resulting from an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to pressure in the brain if left untreated. Hydrocephalus occurs when there is an imbalance between the amount of CSF that is produced and its absorption rate. As CSF accumulates, the ventricles enlarge and the ICP rises.15 Hydrocephalus can be present at birth, as in congenital hydrocephalus, or acquired due to infection, trauma, aging, or tumor. In the United States, approximately 1 in 770 live births develop hydrocephalus.15
Surgical options16 include placement of a ventriculoperitoneal (VP) shunt, in which a shunt drains the CSF into the peritoneum. Another shunt option includes a ventriculoatrial (VA) shunt, draining into the right atrium. An alternative surgical intervention is an endoscopic ventriculostomy (ETV). An ETV may only be used in patients with an obstructive form of hydrocephalus in which drainage of the CSF is blocked due to blood and blood degradation products. Obstructive hydrocephalus is a complication following a subarachnoid hemorrhage. Complications of shunt placement include mechanical failure, valve dysfunction and obstruction, infection, and shunt migration or shunt erosion. Complications of ETV placement include vascular injuries, infection, or sudden pathway closure.16
Trauma-related injury is a leading cause of morbidity and mortality in the United States today. Per the Centers for Disease Control and Prevention, death following unintentional injury was the third leading cause of death in 2019.10 Not all trauma patients require surgical intervention. However, per the American College of Surgeons Committee on Trauma Guidelines,17 any hospital that is designated as a trauma center must ensure that nursing staff caring for the postoperative trauma patients have demonstrated knowledge and skills in the care of trauma patients.
A traumatic brain injury (TBI) or craniocerebral trauma is an injury that affects how the brain works, either temporarily or permanently, and is a leading cause of trauma-related death nationwide.18 The most common mechanisms of injury for TBI include motor vehicle collisions and unintentional falls, followed by assault, intentional self-harm, or accidental injury. The incidence of TBI is highest in ages 0 to 4 and those over the age of 75.19,20
TBI may be classified by a severity index using the GCS20,21 (Table 38.4). Injuries to the brain may include skull fracture, scalp injuries, concussion, contusion, subdural hematoma, epidural hematoma, subarachnoid hemorrhage, intracerebral hematoma, or diffuse brain injury.20,22 The injury becomes more severe in the setting of a depressed fracture, penetration of a foreign object, leakage of CSF, expanding hematomas, or signs and symptoms of brainstem herniation.20 The primary goal is to protect the brain and facilitate the patient’s return to an optimal level of functioning.
Classification of Brain Injury According to the Glasgow Coma Scale20
Glasgow Coma Scale
GCS 13–15 Mild brain injury
GCS 9–12 Moderate brain injury
GCS 3–8 Severe brain injury
While all TBIs require meticulous and frequent neurological assessment, not all require a surgical intervention. The most common etiology of brain trauma requiring a neurosurgical intervention is traumatic intracranial hemorrhage. Although bleeding may begin immediately after impact, it may not be clinically apparent until sufficient blood has accumulated to cause signs and symptoms of intracranial hypertension. Cerebral head trauma can cause hemorrhage beneath a skull fracture or from shearing of the veins or cortical arteries and results in epidural, subdural, subarachnoid, or intraventricular hemorrhage (Fig. 38.4).
An epidural hematoma (EDH), or extradural hematoma, accumulates in the epidural space between the skull and the dura mater. EDH is most often arterial and caused from a rupture or laceration of the middle meningeal artery, which runs between the dura and the skull in the temporal region. EDH may also be seen in the frontal, occipital, and posterior fossa regions. Clinical presentations of an EDH include headache, vomiting, seizures, hemihyperreflexia with a unilateral Babinski sign, ipsilateral pupillary dilation, contralateral hemiparesis, and loss of consciousness followed by a lucid period after which a rapid deterioration occurs. The hemorrhage may be massive, and treatment consists of evacuation of the clot through burr holes made in the skull. Immediate diagnosis and evacuation of the hematoma are associated with lower morbidity and mortality.20
Subdural hematoma (SDH) may result from trauma and the shearing of the bridging veins. Venous blood usually accumulates beneath the dura and spreads over the surface of the brain. A subdural hematoma may be acute (up to 48–72 hours), subacute (2–3 days or up to 2 weeks), or chronic (longer than 2 weeks to several months) depending on the interval between initial traumatic injury and appearance of clinical signs and symptoms. Clinical presentation of an acute SDH includes deterioration of LOC from drowsy to confusion to coma in combination with changes in pupillary response and hemiplegia or hemiparesis. Subacute subdural hematomas fail to show acute signs and symptoms at onset. Brain swelling is not great, but the hematoma may become large enough to produce symptoms. Progressive hemiparesis, obtundation, and aphasia often appear 2 to 14 days after injury. The degree of ultimate recovery depends on the extent of damage produced at the time of injury.20
Chronic subdural hematomas are often seen in older adults. A history of head injury may be lacking because the causative injury is often minimal and long forgotten or deemed insignificant by the patient. The history is usually one of the progressive mental or personality changes with or without focal symptoms as blood slowly accumulates and compresses the brain. The blood itself becomes thicker and darker within 2 to 4 days and within a few weeks resembles motor oil in character and color. Papilledema may be present. Chronic subdural hematomas can mimic any disease that affects the brain or its coverings. Treatment consists of evacuation of the defibrinated blood through multiple burr holes or a craniotomy incision.20
Immediate surgical intervention is recommended for any symptomatic patient with an SDH greater than 10 mm in thickness or associated with a midline shift.20 Goals of surgery include rapid clot evacuation, bleeding control, and resection of nonviable brain tissue. Surgical approaches include burr hole placement followed by craniotomy for clot evacuation. An external drain may be placed for continued drainage (Box 38.2).
If a surgical drain is present, confirm with surgeon whether the drain is to gravity drainage or suction. If an EVD (external ventricular drainage) is present, confirm with surgeon correct leveling and continuous versus intermittent drainage. Verify frequency for output measurement.