Care before and after your operation

Before the operation

The tests. We ask for blood tests including clotting, a blood group, an electrocardiogram and, depending on age and medical history, a medical or cardiology assessment. The CT scan that made the diagnosis must be available on the day of surgery: bring the disc and the report, even if the scan was done in the same hospital.

If you are given a date a few days away, that is not neglect. This operation is almost never an emergency of minutes: in a series of 179 patients, the mean time between the CT scan that made the diagnosis and the operation was 76 hours, and that delay was not associated with higher mortality, a worse outcome or more reoperations¹. What does bring the date forward is a new or worsening symptom. If that happens, tell us.

Fasting. The anaesthetic team will tell you your fasting times, and they vary with the technique planned and with your clinical state. There is no scheme specific to this operation, so we will not give you hours here: ask for them in writing and keep to them. It is worth knowing that modern fasting is not automatically «nothing since last night», and that in an older person an unnecessarily long fast has its own cost —dehydration, low blood pressure, confusion—. If you are given a time that leaves you many hours without fluid, ask whether you may have clear fluids closer to surgery.

Medication. Bring the full list, with names and doses, including over-the-counter medicines, drops, inhalers and supplements. And one rule with no exceptions: do not stop or restart anything on your own. What is stopped, how many days beforehand and what replaces it is decided by the team, with your medical history in front of them.

It is worth understanding why that decision is not obvious. Almost half of the people with this diagnosis take anticoagulants or antiplatelet drugs —medicines that make the blood harder to clot—: over twenty-five years that proportion went from 27 % to 49 %². Taking an anticoagulant before surgery was associated with more recurrences —the haematoma forming again— and more postoperative bleeding; with antiplatelet drugs that association was weaker and did not reach statistical significance³. But the reason they are being taken —atrial fibrillation, a heart valve, a previous clot— does not disappear in theatre: in that same analysis, of 47 studies and 16,288 operated patients, those who had been taking these drugs had around three times as many thromboembolic complications —clots and emboli— around the time of surgery³. That comparison is between people who take them and people who do not, so it mostly measures the disease that makes them necessary: nobody has yet compared stopping with not stopping. Two findings make the decision less dramatic: how many days the antithrombotic is stopped before surgery did not change the recurrence rate⁴, and aspirin taken before surgery was not associated with more recurrences either⁵.

The rest of your usual medication —blood pressure, thyroid, Parkinson's, asthma— is generally continued, often with a sip of water on the morning of surgery. Insulin, diabetes tablets and diuretics are usually adjusted. Ask for it in writing.

What to bring.

• Identity documents and your insurance or health-cover details.
• The disc and the report of the CT scan, and any earlier scans you have.
• The list of medicines with their doses; if you can, the boxes themselves.
• Your glasses, your hearing aid and your dentures, with their cases. With them you will be better oriented after the operation; without them, many people look more confused than they are.
• Comfortable clothes that fasten at the front, closed shoes with non-slip soles, and toiletries.
• Your stick or your walking frame, if you use one.
• Nothing valuable: no jewellery, no money.

Who comes with you. Come with someone, and ask that person to be there when we explain the discharge: in hospital people retain little of what they hear, and even less if the reason for the operation was confusion in the first place. Arrange as well who will be at home for the first few days. As a benchmark, after a head injury it is recommended that a responsible adult stays with the person for the first 24 hours⁶: that is a good floor for the first days at home. If you live alone, say so before surgery, because it changes the discharge plan.

What we are going to do

We operate through burr holes. In plain words: we shave a small patch of hair —not the whole head—, we make one or two small openings in the bone, we wash out the collected fluid with warm saline until it runs clear, and we leave a drain, a fine tube that carries on clearing what remains. No large window is opened in the skull, and the surgery is not on the brain itself but on the fluid pressing on it.

We will probably suggest operating with you awake, under local anaesthesia with sedation: the area is numbed, you breathe on your own, and you often do not remember much of the procedure. This is not a lesser version of the operation. Across 18 studies and 4,367 patients, general anaesthesia did not change recurrence, mortality or the need for reoperation, but it was associated with 2.4 times more complications⁷; with local anaesthesia, the operation and the hospital stay also tend to be shorter⁸. Honesty is due here: these are observational studies, and frailer patients tend to be given a general anaesthetic, which explains part of the difference. If you cannot lie still, or if the team judges it safer, it is done asleep, and that is fine too.

It is a short operation: it is counted in minutes, not hours. The family's wait is considerably longer than that, because it includes preparation, anaesthesia and immediate recovery. Several hours passing before they can see you does not mean anything has gone wrong.

The drain comes out through a small opening next to the wound and runs into a bag or a bottle. It bothers people less than they expect, and it does not stop you moving, sitting up or walking.

The first few days

Where you wake up. If you had local anaesthesia, you are awake from the start and go to your room or to a high-dependency area. If it was a general anaesthetic, you go through the recovery room first. It is normal to have a dressing round your head, a sore throat if a tube was used, and to be sleepy for the rest of the day.

The drain. We take it out at around 24 hours, almost always the next day. It comes out in bed, in a few seconds, and it hurts little. The timing is not arbitrary: in a trial of 347 patients, symptomatic recurrences at 3 months were 27 % with the drain left in for 6 hours, 20 % with 12 hours and 10 % with 24 hours⁹.

Getting up. Get up early: staying in bed brings more complications. We will raise the head of the bed within the first 12 hours, and have you sitting, standing and walking as soon as you can tolerate it, with the drain still in. This is part of the treatment, not a concession and not a rush for the bed.

For years the opposite was advised: 48 hours in bed with the head down. A trial of 208 patients compared the two approaches. Medical complications —infection, seizures, clots— were 19.2 % with early mobilisation against 34.6 % with bed rest, and no increase in recurrence was detected, though with 208 patients the trial was not large enough to rule out a small difference¹⁰. At one year, a favourable functional outcome was reached by 76.5 % with early mobilisation against 58.4 % with bed rest¹¹. Moving early does not put the result of the operation at risk: it protects it.

Pain. It is usually mild or moderate and responds to ordinary painkillers. Take them by the clock for the first few days, without waiting for the pain to arrive: it is better controlled that way. Tell us if the pain grows day by day instead of easing, if it comes with vomiting, or if your alertness changes.

The commonest complication is not in the head. In the drainage trial it was an infection —between 17 % and 23 % of patients depending on the group— and in most cases it was urinary⁹. That is why we insist on getting up, walking, drinking fluids and removing the urinary catheter —the tube that drains urine— as soon as possible.

How long the hospital stay is. A few days, with no fixed number. It depends less on the operation than on how you were beforehand: on your strength, your balance, your other conditions and whether there is someone to look after you at home. Local anaesthesia is associated with shorter stays⁸.

A note for the family. Older patients are often more confused for the first few days, particularly at night. It helps to have their glasses and hearing aid on, to have daylight in the room, to have someone familiar there, and to be reminded matter-of-factly where they are and why. It usually improves as they get up, sleep at night and return to their routine.

The wound

Keep it clean and dry. If a dressing —the gauze covering the wound— was left on, change it as instructed and with washed hands. If you were told to leave the wound open to the air, leave it open to the air: do not cover it just in case. Do not scratch it or pick off the scabs, however much they itch.

Washing your hair. You will be able to sooner than you think, but the day is set by your team: it depends on how the wound was closed, and there is no single deadline and no study that sets one. When they give you the go-ahead, use warm water and a mild shampoo, do not rub the area, rinse well and pat it dry. No hot hairdryer and no hair dye until the wound is closed and free of scabs. Putting your head under water —bath, swimming pool, sea— waits considerably longer.

Stitches or staples. They come out at the first follow-up appointment. The timing depends on the material used and it must be written in your discharge summary; if it is not there, ask before you leave hospital. Some stitches dissolve on their own and there is nothing to remove.

What is normal. Soft swelling around the wound. A bruise that over the following days tracks down towards the eye or the neck under gravity and changes colour. Some firmness under the scar. Numbness, tightness or itching of the skin in the area, which can last months. A small dip where the opening in the bone was: it does not fill in, and it does not matter.

What is not normal. Redness that spreads, local heat, pain that increases day by day, discharge or fluid leaking out, edges that open, and fever. Any of these is a reason to seek help the same day.

At home: what you can and cannot do

A warning before the list: almost none of this advice has a trial behind it. What has been studied is the general principle —moving early protects, prolonged rest harms¹⁰¹¹— and we apply it to the weeks at home as well. The specific deadlines vary between teams. Where there is no evidence, we say so, and we say who decides.

Walking. Every day, several times, indoors and outdoors. Start with someone alongside you. It is the most useful thing you can do.

Effort, lifting and bending. For the first weeks, avoid lifting weight, pushing furniture, straining with your breath held, and bending with your head below your waist; to pick something off the floor, bend your knees. No study sets a maximum weight or a date: your team will give you the timing, based on how the wound closes and how you are doing.

Falls. This is where you can do most. Another fall is exactly the mechanism by which most of these haematomas appeared: among patients aged 80 or over, in 54 % of cases it was a fall from their own height². Take up loose rugs and clear cables, leave a light on in the hallway and the bathroom, wear closed shoes, fit a grab rail in the shower, have your eyesight checked, and do not get out of bed suddenly. If you take sleeping tablets or tablets for anxiety, ask whether you can stop them: they cause dizziness and falls.

Alcohol. Do not drink alcohol while you are taking painkillers, or during the first weeks. After that, ask: the answer depends on your medication, and alcohol makes falls more likely.

Driving. Do not drive until your team says you may. There is no deadline set by any study, and practice varies widely. Three things weigh in: whether you had a seizure —in which case the deadline is set by the driving authority in your country or region, not by the surgeon—; whether you are left with confusion, slowness, weakness or double vision; and what your insurer requires. Check the local rules before you get back behind the wheel.

Going back to work. It depends on the work and on the state you are left in. A desk job is resumed sooner than one demanding physical effort, heights or driving. There are no good published data on return to work after this operation: nobody has measured it properly, largely because most of these patients are already retired. It is decided case by case.

Flying. There are no studies setting a date here either. In practice one thing weighs most: when the haematoma comes back, it tends to come back early —the mean time to reoperation was 47 days¹²— so for the first weeks it is better to be near somewhere that can assess you and scan you. If you are going to travel anyway, tell us beforehand, take the discharge summary and the images with you, and find out where to go at your destination.

Sport. Walking, a stationary bike and gentle activity, the sooner the better. Swimming, once the wound is closed and your team agrees. Contact sports, or anything with a risk of a blow to the head —including cycling on the road or climbing a ladder— wait for explicit clearance. No study sets that deadline.

Medication at home

For pain. Paracetamol is the mainstay and is generally enough. Keep to the maximum daily dose you were given. Do not take anti-inflammatories —ibuprofen, diclofenac, naproxen— or aspirin on your own: they interfere with clotting, and this is a problem that can bleed again. Before adding any new medicine, including anything bought over the counter, ask.

The anticoagulant. This is the hardest question in the whole treatment, and it has to be answered honestly: there are still no evidence-based guidelines on when to restart it¹³. Do not restart it on your own, and do not put it off out of fear either. We give you the date, in writing.

What is known today. In 291 patients with atrial fibrillation operated on for a chronic subdural haematoma, restarting the anticoagulant within 14 days, compared with not restarting it in that window, gave a 90-day reoperation risk of 11.7 % against 9.4 %: a difference that may not be real¹⁴. On the other side, prolonged withdrawal is associated with more clots and emboli, and in most series the antithrombotic was restarted within the first two weeks⁴. About a quarter of these patients take it for atrial fibrillation¹³, and an international trial now under way compares restarting at 5 days with restarting at 30¹³. Until it reports, the decision is made case by case: it weighs your reason for anticoagulation against what the scan shows.

Aspirin and the other antiplatelet drugs. They are usually restarted sooner and with less argument: taken before surgery, aspirin was not associated with more recurrences⁵.

Anti-seizure medication. A mild blow to the head with a normal CT scan does not call for medication to prevent seizures, and that is not an oversight. The guidelines that discuss that prevention deal with moderate to severe injury requiring admission, and even there they do not make it obligatory: the current recommendation is that it may be used or not used and that, if it is used, it should be levetiracetam and for 7 days or less¹⁵. The trial that founded the practice already showed why: phenytoin reduced seizures in the first week —3.6 % against 14.2 %— and not those that came later¹⁶. If you have been prescribed one, ask what the stop date is, and do not abandon it on your own before that date.

The follow-up appointments

When. The first appointment is the wound check: that is when we take out the stitches or staples and go over your strength, your walking and your alertness. The ones after that are spaced out. The dates are set by your team and must be written in the discharge summary; if they are not, ask for them before you leave.

The follow-up CT scan. Not every team asks for one routinely, and that is not carelessness: there is no standard. Comparing two hospitals with opposite policies —a median of 4 scans in the following six weeks against 0— there were no differences in patient outcomes¹⁷¹⁸. In a nationwide survey in Thailand, 66 % of neurosurgeons did not request a routine postoperative scan¹⁹.

Fluid still showing on the scan is not a failure. If you have a follow-up scan and fluid can still be seen where the haematoma was, that is what is expected: the brain was compressed for weeks or months and takes time to fill that space again. The numbers are reassuring. One week after surgery, 81 % of patients had no symptoms; yet residual haematoma could still be seen in 65 % at 3 months and in 15 % at 6 months, and those findings did not predict the clinical result²⁰. Only 3.9 % needed a reoperation²⁰. Reoperation follows clinical deterioration, not an image: what matters is how you are, not how the scan looks.

If you are not being operated on

Watching without operating is a legitimate decision when the collection of fluid is small and the symptoms are few. It is not doing nothing: it is keeping watch.

What we watch. Above all, how you are. The follow-up is clinical, and the appointments exist so that we can compare: how you walk, how you think, how you speak, how strong you are. Bring someone who lives with you, because these changes are easier to notice from outside.

What should make you seek help before the appointment is due. A headache that changes or worsens, more confusion or slowness, a change in personality, unsteadiness when walking, new falls, weakness or numbness down one side, difficulty speaking, new incontinence, drowsiness.

Ending up in theatre does not mean the first decision was wrong. Of 2,095 patients with few symptoms managed without surgery, 19.8 % ended up needing rescue surgery²¹: one in five. That is why the follow-up appointment is kept even if you feel well.

Headache, without self-medicating. If you need something for pain, use paracetamol. Do not take anti-inflammatories —ibuprofen, diclofenac, naproxen— or aspirin on your own initiative: they interfere with clotting, and the haematoma is still there. And a headache that is getting worse is not a dosing problem: it is a reason to seek help, not to increase the painkiller.

Two warnings. Symptoms can appear weeks or months after the blow, and sometimes with no blow anyone remembers: only 59 % of patients had a documented injury². And if you take anticoagulants or antiplatelet drugs other than aspirin alone, seek help at a lower threshold: a normal initial CT scan does not rule out bleeding that appears later⁶.

If a piece of bone has been left out

This does not happen to most people, and it does not happen with burr-hole surgery. It applies to anyone who has had a craniectomy: the operation in which part of the skull is removed and not replaced at the time.

The helmet. Wear it as instructed, every time you get out of bed. While the bone is missing, that area has no protection: do not lean on that side, and stay away from places where you could be knocked. In all honesty: there are no studies showing that the helmet prevents injuries. The only study with random allocation, in 58 patients, measured something else —satisfaction with appearance, willingness to take part in social life, and fear of an accidental knock— and all of that improved with the helmet at weeks 4 and 8²². We advise it anyway, on common sense.

The cranioplasty. Putting the bone back is a second planned operation, not a cosmetic formality. On the best moment there is no consensus: across 18 studies and 2,226 patients, overall complications did not differ between doing it before or after 90 days, and what weighed most was not the date but the implant material²³. Your team will explain which material they propose and why.

Syndrome of the trephined, and why to tell us. There is a medical reason not to postpone the cranioplasty indefinitely. While the bone is missing, some people get worse: the skin over the area sinks in and weakness, slowed thinking or difficulty speaking appear. That has a name —syndrome of the trephined— and it has a remedy. It appears on average about five months after the craniectomy, comes with a visibly sunken skin flap in 93 % of cases, causes motor deficits in 57 %, cognitive problems in 41 % and language problems in 28 %, and it improves within about four days of the bone being replaced²⁴. If you notice the area sinking more than before, or if any of those symptoms appear weeks or months later, tell us. Do not put it down to tiredness or to age.

When to seek help without waiting

These are two different lists, depending on where you are today. Read them with whoever is looking after you, and keep them to hand.

The questions people ask most