Post - Traumatic Thick Acute Subdural Hematoma in Child Showing Rapid Deterioration Managed with Burr - Hole Evacuation Surgery with Drain: A Novel Rescue Technique

Children with post-traumatic intracranial haematoma causing mass lesion need surgical evacuation. Usually craniotomy is the preffered method and different approaches are decompressive craniotomy, hinge cranioplasty after hematoma evacuation or evacuation of acute subdural hematoma (ASDH) with expansile duraplasty. However all these procedure are time -consuming, require general fitness of anaesthesia and normalisation of raised of intracranial pressure following haematoma evacuation may not occur till dural opening, which is approximately an hour after beginning of scalp incision till raising bone flap, and most important is the availability of operation theatre and anaesthetist dedicated for that case, and excessive patient load with limited operation theatre facility and lack of trained anaesthetist in developing country with resource constrained and limited skilled man power. Authors report an interesting case a 2-year child, who had thick fronto-temporoparietal acute thick subdural hematoma following trauma , was initially planned for decompressive craniotomy, however, he developed rapid neurological deterioration, so he was taken up for surgery in between scheduled routine cases. He underwent brurrhole evacuation of ASDH and drain placement. After hematoma evacuation, he was kept on ventilatory support for three days. The postoperative noncontract CT scan head revealed complete evacuation of ASDH with no residual hematoma and subsidence of complete mass effect with opening of Sylvian fissure, sulci and basal cisterns. A subgroup of cases may possess a special challenge in the management, who develop very rapid deterioration in the current neurological status while awaiting in the emergency for surgical intervention. [1, 2] Overall the prognosis of ASDH is usually unfavourable in the cases of head injury associated with coagulant disorder and associated intracerebral contusion and laceration. [3] Authors advocates an emergent burrhole with drainage tube placement technique for evacuation of thick acute subdural hematoma, as an alternative method in the desperate situation of non-availability of routine operation theatre in attempt to save life and halt progression of the secondary brain injury.