20 the Role of Surgery for Intracranial Mass Lesions after Head Injury

Many uninformed neurosurgeons have regarded surgery for post-traumatic intracranial hematomas as unrewarding. This pessimism is based on the belief that outcome is determined principally by the magnitude of the initial injury and, therefore, frequently remains poor despite optimal surgery. In fact, management of post-traumatic epidural hematoma is one of the most ‘cost-effective’ of neurosurgical procedures in terms of quality of life and years preserved (Pickard et al., 1990). It is particularly in those with moderate head injury that hematoma management may make the difference between survival with permanent disability and a good outcome. Intracranial hematoma is by far the most common cause of secondary deterioration after all head injuries and constitutes over 70% of the causes of death in patients who ‘talk and die’ (Reilly et al., 1975; Rose, Valtonen and Jennett, 1976). Emergency surgery for post-traumatic intracranial hematomas may be among the most difficult procedures performed by neurosurgeons because of the frequency of complications such as heavy bleeding and brain swelling yet, because these operations frequently occur at night, it is too often the less experienced surgeons who are delegated to do them. Similarly, decisions regarding removal of hematomas, particularly contusions and intracerebral hematomas, may be extremely difficult, especially so when surgery is prophylactic and intended to prevent deterioration. There have been major changes in the patterns of management of intracranial hematoma in recent years, and this chapter has in mind neurosurgeons in training and aims to provide some guidelines for surgical management.