After a traumatic brain injury, there are conditions that necessitate surgery. Many are related to bleeding.

An epidural hematoma is a blood clot that occurs with injury to the arterial blood vessels crossing between the skull and outer lining of the brain, called the dura mater. There is often a skull fracture associated with an epidural hematoma. The skull fracture can lacerate a meningeal artery. Because an artery has significant blood flow, the hematoma will occur rapidly. It will press on the brain. The diagnosis of an epidural hematoma is made by CAT scan. The clot must then be evacuated surgically.

A subdural hematoma occurs on the other side of the dura, between the dura and the brain tissue. An acute subdural hematoma usually occurs because of severe brain trauma. The veins from the surface of the brain to the dura are torn, and the venous blood forms the hematoma. The elderly are more at risk for subdural hematomas because their veins are thinner and more brittle. This condition is also diagnosed by CAT scan and usually must be drained surgically.

Hemorrhages inside the brain itself can occur from trauma. They can be within the brain tissue, like contusions, or there can actually be a clot formed inside the brain. These would also be seen on CAT scan. If the patient is in a coma or has a significant neurologic deficit, the clot would be removed surgically.

Skull fractures are diagnosed by x-ray. Linear fractures that are not depressed heal on their own and do not usually need surgery. Depressed skull fractures need to be elevated if they are compressing the brain. Shattering of the skull, as can happen with a gunshot wound, can push skull fragments into the brain, and they must be removed if surgery is attempted. Basilar skull fractures occur at the bottom part of the brain and are more dangerous than fractures of the rest of the skull. They break the barrier between the inside of the skull and structures outside of it. Cerebrospinal fluid can leak out, and be seen coming out of the nose or ears. Blood can be seen behind the ear drum. Blood can dissect out under the skin and show up around the patient’s eyes. Their appearance gives them the name “raccoon eyes.” Basilar fractures do not usually need surgery unless the dura needs to be repaired. Patients are often treated with antibiotics because there is communication between the brain and outside.

A patient with an open wound on the scalp that communicates with a skull fracture, an “open fracture,” will also need antibiotics. Scalp wounds in general will be sewn up or sutured regardless of other injuries if the patient is stable.

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