First, acute subdural hematoma develops rapidly, especially in extremely acute cases, and the mortality rate is as high as 50% ~ 80%. Once the diagnosis is made, it is urgent to race against time and have surgery as soon as possible. In subacute subdural hematoma, some cases with mild primary brain injury and slow development can also be successfully treated by non-surgery under strict intracranial pressure monitoring or dynamic observation of ct scanning. However, if the condition worsens during the treatment, it is very dangerous to switch to surgery.

(1) surgical treatment: the choice of surgical methods depends on the condition. There are three commonly used surgical methods:

① Borehole irrigation and drainage: according to the hematoma position shown by CT, borehole drainage is carried out. If it is an emergency drilling exploration that cannot be located before operation, it should be drilled in turn according to the injury mechanism and lesion location, combined with the patient's clinical manifestations. If the injury is contralateral, a hole should be drilled in the front of the temporal bone, then the forehead and then the top. If it is a direct blast injury, drill a hole in the force-exerting part first, and then drill a hole in the hedging part. After the hematoma is found, the drilling hole should be slightly enlarged to facilitate washing and removing the hematoma. If it is a liquid hematoma and there is no active bleeding, you can drill 1 ~ 2 holes in the thick part of the hematoma, and then flush most of the hematoma through the intubation between the holes. At this point, if the intracranial hypertension is relieved and the brain beats well, the operation can be terminated. Leave a drainage tube in the lower position, continue to drain for 24 ~ 48 hours, and suture the scalp in layers. Children with acute subdural hematoma with open portal can be gradually discharged by repeated aspiration through the side corner of the front chimney. If it is a solid hematoma, it needs drilling and drainage or craniotomy to remove the hematoma.

② craniotomy with bone window or bone flap: suitable for patients with definite hematoma position; After drilling exploration, it was found that the hematoma was clot-like, which was difficult to flush and discharge. In the process of drilling, washing and drainage, blood keeps flowing out; Or after removing the hematoma, the brain tissue swells rapidly and the intracranial pressure rises again. The drilling hole should be enlarged into a bone window or craniotomy should be carried out immediately. Under the premise of good exposure, fully remove hematoma and crushed and eroded brain tissue, and stop bleeding properly. If necessary, brain puncture was performed to clear the hematoma in the brain, and brain puncture drainage or brain basal cistern drainage was performed. After operation, the dura mater and scalp were sutured as usual, and 24 ~ 48 rubber were drained outside the dura mater. If the intracranial pressure improves once and rises again after the hematoma is cleared, drilling exploration should be tried in the position where multiple intracranial hematoma may exist. Especially the forehead, temporal base and deep brain, brain scanning should be carried out with the help of intraoperative B-ultrasound when necessary. After confirming that there is no other hematoma, it is feasible to decompress under the temporal muscle or remove the bone flap. Ventricular puncture and/or tentorium cerebelli incision and basal cistern drainage should be performed. When in doubt, CT scan or cerebral angiography should be performed to rule out the possibility of missing hematoma or delayed hematoma.

③ Subtemporal decompression or decompressive craniectomy: When acute subdural hematoma is accompanied by severe brain contusion, brain edema or brain swelling, even if the hematoma and brain tissue fragments are completely removed, the intracranial pressure cannot be effectively relieved. When the brain tissue is still swollen, suboccipital decompression and decompressive craniectomy are needed. If necessary, the affected frontal and temporal poles should be removed as internal decompression measures, and then the cranial cavity should be closed.

1. Subtemporal decompression: Subtemporal decompression is a traditional operation. As a decompression operation after acute brain contusion and laceration with subdural hematoma clearance, the scope of decompression was expanded, reaching a diameter of 8 ~ 10 cm but not exceeding the coverage of temporal muscle. After the temporal muscle is completely peeled off from the skull surface, the scales of the temporal bone and some adjacent parts of the frontal bone and parietal bone are bitten off. Then the dura mater was cut open in a star shape to reach the edge of the bone window, and the temporalis muscle was sutured after hemostasis, but the temporalis muscle fascia was not sutured for decompression. No drainage, layered suture scalp. Unilateral decompression is usually performed, and bilateral infratemporal decompression is also feasible if necessary.

2. Bone flap decompression: The so-called bone flap decompression means giving up the bone flap, opening the dura mater, and only suturing the scalp for decompression. Usually, it is called a large bone flap unless it is decided to remove the bone flap and decompress it before operation, and the bone flap is intentionally enlarged. Otherwise, the size and position of the bone flap can hardly meet the requirements of decompression. In fact, whether it is necessary to take decompression measures is mostly decided during the operation. Therefore, after the bone flap is discarded, it is often necessary to remove the sphenoid wing from the scale of the temporal bone down to the zygomatic arch level and forward to the posterior part of the orbital process of the frontal bone, so that the temporal lobe and part of the frontal lobe protrude outward and reduce the pressure on the brain stem and lateral fissure blood vessels. However, it must be emphasized that the indications of decompressive craniectomy should be strictly mastered, and the craniectomy should not be abandoned at will. It should be noted that after decompression with large bone flap, brain displacement, deformation and massive flow disorder of brain parenchymal water caused by encephalocele may lead to delayed intracranial hematoma and local edema aggravation in the early stage, brain structure deformation and distortion, increased nerve defect, and may also lead to complications such as brain softening, atrophy, effusion, perforation deformity, hydrocephalus, epilepsy and so on in the later stage. The indications of large bone flap decompression are: acute or extremely acute intracranial hematoma with severe brain contusion and/or brain edema, brain hernia has been formed before operation, intracranial hypertension is not relieved satisfactorily after hematoma removal, and there is no other residual hematoma; Diffuse brain injury, severe brain edema, cerebral hernia formation, but no localized large hematoma should be excluded; Before the operation, mydriasis and craniotomy were performed, and after the hematoma was removed by operation, the intracranial pressure improved once, but soon increased again.

If the acute subdural hematoma belongs to the elderly, the prognosis is very poor. If the binocular astigmatism reaction disappears, the hematoma is small and the condition is serious.

(2) Non-surgical treatment: Acute and subacute subdural hematoma should be treated promptly and reasonably, regardless of surgery or not, especially after acute hematoma surgery. Although some acute subdural hematomas can dissipate automatically, they are rare and can't be taken chances. In fact, only a few patients with subacute subdural hematoma can be treated by non-surgery as long as the primary brain injury is mild and the disease develops slowly. Indications: conscious, stable condition, basically normal vital signs, and gradually relieved symptoms; I have nerve damage caused by local brain compression; CT scan showed that the ventricle and cistern were not obviously compressed, the hematoma was less than 40ml, and the midline displacement was less than10 mm; The monitoring pressure of intracranial pressure is below 3.33 ~ 4.0 kPa (25 ~ 30 mmHg).

Second, the treatment of chronic subdural hematoma: once the symptoms of increased intracranial pressure appear, surgery is necessary.

1. The preferred method is drilling and drainage, and the effect is satisfactory. If there are no other complications, the prognosis is better. Therefore, even if the patient is seriously ill in his old age, he should try his best to treat it, and even carry out bedside craniotomy drainage. As long as the treatment is timely, he can often turn the corner.

① Drilling or cone hole irrigation and drainage: two holes (one high and one low) are selected according to the location and size of hematoma. Under local anesthesia, the skull drill or skull cone is used before the first part. After entering the hematoma cavity, old blood and brown broken blood clots will flow out, and then carefully put them into the capsule cavity with silicone tube or No.8 catheter, and the length should not exceed the radius of the hematoma cavity, so as to further drain the liquid hematoma. Similarly, drill a cone hole or drainage in the lower part (rear part), then place the catheter, then pass the catheter through the two catheters, and gently and repeatedly wash the washing liquid with physiological saline until the washing liquid becomes clear. After operation, two drainage tubes were led out of the skull by scalp puncture, and then connected with sterile sealed drainage bags. The high drainage tube is exhausted and the low drainage tube is drained, which can be removed in about 3 ~ 5 days. Recently, it has been reported that simple craniotomy can be used, and the old blood can be discharged directly through the scalp at the bedside, and then washed with normal saline until it is clear. Craniotomy is performed every 3-4 days, usually about 2-4 times, until the brain compression is relieved and the midline structure is reset under CT monitoring.

② Subdural puncture of the lateral corner of the front chimney: For children with chronic subdural hematoma and patent front chimney, subdural puncture is feasible to aspirate the blood in the front chimney. Select the muscle needle with short oblique needle tip and obliquely penetrate the forehead or parietal dura mater through the lateral corner of the front chimney at a 45-degree angle. When the needle is inserted 0.5 ~ 1.0 cm, the brown liquid will be pumped out, and the pumping amount is 15 ~ 20 ml each time. If both sides need to be punctured alternately, the blood drawn is often thinner every day, and the volume of hematoma is also reduced. If blood is drawn and/or the hematoma does not shrink, incision should be used instead.

2. Craniotomy with bone flap to treat chronic subdural hematoma;

Suitable for chronic subdural hematoma with thick capsule or calcification. The incision method is as described above. After opening the bone flap, the blue-purple thickened dura mater can be seen. First, make a small incision and slowly drain the accumulated blood. When the intracranial pressure drops slightly, the dura mater and the hematoma adventitia directly below it are cut into flaps and spread together to reduce bleeding. Hematoma intima and arachnoid membrane are not healed and easy to separate, so they should be taken out, but they should not be pulled hard to avoid tearing the junction of intima and membrane, which is easy to bleed. They can be cut at the proximal edge of 0.5cm, properly stop bleeding after operation, suture the dura mater and scalp layer by layer, and drain the hematoma cavity for 3 ~ 5 days. Bilateral hematoma should be operated by stages.

3. Treatment of postoperative hematoma recurrence: No matter drilling, irrigation and drainage or craniotomy, there is the problem of hematoma recurrence. The common causes of recurrence are: brain atrophy in elderly patients and difficulty in brain swelling after operation; The hematoma sac is thick and the subdural cavity cannot be closed; There is a blood clot in the hematoma cavity that cannot be completely removed; Hematoma recurrence caused by fresh bleeding. So pay attention to prevention. After operation, the head should be lowered, the affected side should lie flat, drink plenty of water, do not use strong dehydrating agent, and replenish hypotonic fluid appropriately if necessary. Those with thick capsule or calcification should be removed by craniotomy; When there is a solid blood clot in the hematoma cavity, or when there is fresh bleeding, bone flap or bone window should be used for craniotomy to completely remove it. After operation, the drainage tube was exhausted at high position and drained at low position, all of which were externally connected with a closed drainage bottle (bag) and injected with normal saline through lumbar puncture or ventricle. Postoperative residual cavity effusion, pneumatosis absorption and brain swelling need 10 ~ 20 days, and dynamic CT observation should be made. If the clinical symptoms are obviously improved, there is no need to rush to reoperation even if there is effusion in the subdural cavity.