Bila perdarahan/hematoma epidural walaupun jarang dilakukan explorative Burrhole dan bila positif dilanjutkan dengan kraniotomi, evakuasi hematoma dan hemostasis yang cermat .
Pada perdarahan/hematoma subdural, tindakan explorative burrhole dilanjutkan dengan kraniotomi, pembukaan duramater, evakuasi hematoma dengan irigasi menggunakan cairan garam fisiologik. Pada perdarahan intraventrikuler karena sering terdapat obstruksi aliran likuor, dilakukan shunt antara ventrikel lateral dan atrium kanan.
INTRACRANIAL HAEMORRHAGE
There are three important and often interrelated causal factors, namely prematurity, anoxia and trauma. Other predisposing factors such as congenital anomalies of the brain or cerebral blood vessels must not be overlooked. The injuries that lead to permanent damage range from the immediately obvious, like massive subdural haemorrhage or spinal cord injury, through minor degress of intraventricular bleeding or cerebral oedema to those still obscure adverse influences on the brain which result in cerebral palsies, mental retardation, minor brain dysfunction syndromes or even mental illness. It must be emphassied that trauma can be purely mechanical in origin. The associations between the main types of intracranial haemorrhage, gestational age and precipatiting events are shown in Table 37.2.
All areas of the brain can be affected. Large fatal subdural haemorrhages are now less common and intraventricural haemorrhage is the main form of trauma seen at autopsy (Levene et al 1985).
Types of haemorrhage
Subdural haemorrhage
This almost exclusively traumatic lesion is seen both at term and preterm (Volpe 1981). The soft, compressible skull of the preterm infant, precipitate labour, cephalopelvic disproportion, excessive compression of the fetal head during labour and forceps manoeuvres are predisposing factors. In flexed vertex presentation compression of the head occurs along the occipitofrontal diameter and in a face or brow presentation between vault and skull base (Menkes 1984). The tentorium, or more rarely the falx cerebri, is stetched and torn, usually where the two membranes join, causing rupture or thrombosis of engorged dural sinuses and cerebral veins. Excessive overriding of the parietal bones may lead to laceration of the sagittal sinus. Signs of subdural haemorrhage are those associated with severe asphyxia, cerebral irritation and a bulging anterior fotanelle due to cerebral oedema. Diagnosis is confirmed by ultra sound examination.
Subdural taps may be required to drain large collections of blood. Supportive treatment is gerared towards controlling the consequences of asphyxia and raised intracranial pressure.in survivors, residual symptoms may range from none (50-80%) to a hyperalert state and sometimes focal signs with paralysis.
Subarachnoid haemorrhage
This haemorrhage occurs when small amounts of a capillary or venous bleeding take place in the subarachnoid space following mild trauma or asphyxia at delivery. It often goes undiagnosed as many babies are asymptomatic; consequently this form of haemorrhage appears less common than it rally is. The condition is suspected at lumbar puncture when the cerebrospinal fluid is uniformly blood-stained. A subarachnoid haemorrhage does not usually show up on ultrasound scan but a scan should still be perfomed to rule out other types of intracranial hemorrhage. Treatment involves the control of the consequences of asphyxia and the control of convulsions. Hydrocephalus is a complication of subarachnoid hameorrhage and regular measurements of the occipitofrontal circumference should be made and chrted. Ultrasound examination of intracranial structures should be made if hydrocephalus is suspected.
