61312

Craniectomy or Craniotomy for Supratentorial Hematoma Evacuation

CPT code 61312 describes a major neurosurgical procedure involving either a craniectomy or a craniotomy to evacuate an extradural (epidural) or subdural hematoma located in the supratentorial compartment of the brain. The supratentorial region includes all structures located above the tentorium cerebelli, specifically the cerebral hemispheres. This procedure is typically performed in an emergent or urgent setting to relieve life-threatening intracranial pressure caused by the rapid accumulation of blood. In an epidural hematoma, blood collects between the inner table of the skull and the dura mater, often due to a rupture of the middle meningeal artery. In a subdural hematoma, blood collects between the dura mater and the arachnoid membrane, usually from tearing of bridging veins. The surgeon begins by making a large scalp incision to expose the skull. Burr holes are drilled, and a saw is used to remove a bone flap. If the hematoma is extradural, it is evacuated immediately upon removal of the bone. If it is subdural, the dura mater is incised to gain access to the clot. The hematoma is removed using a combination of suction, irrigation, and manual extraction. Following evacuation, the surgeon must identify and control the source of bleeding. If the brain is excessively swollen and cannot be safely contained, the bone flap may be left off (craniectomy); otherwise, it is secured back in place (craniotomy). This code encompasses the entire process of access, evacuation, and closure.

Clinical Indications

  • Acute traumatic subdural hematoma with midline shift or significant mass effect
  • Epidural hematoma with a volume greater than 30 cm3 regardless of GCS
  • Symptomatic chronic subdural hematoma failing conservative management
  • Nontraumatic spontaneous subdural hemorrhage with neurological deterioration
  • Acute intracranial hypertension due to supratentorial blood collection
  • Progressive neurological deficit associated with radiological evidence of hematoma

Procedure Steps

  1. The patient is placed in a supine or lateral position under general anesthesia with the head secured in a stabilizing frame.
  2. A scalp incision (often a large question-mark shape) is performed to provide adequate exposure of the skull over the hematoma site.
  3. One or more burr holes are drilled into the skull using a surgical perforator.
  4. A craniotome is used to connect the burr holes and elevate a bone flap.
  5. For extradural hematomas, the clot is removed directly from the surface of the dura mater.
  6. For subdural hematomas, the dura mater is incised and reflected to expose the underlying blood collection.
  7. The hematoma is evacuated using gentle suction and warm saline irrigation.
  8. Active bleeding sources, such as bridging veins or arterial branches, are controlled using bipolar electrocautery or hemostatic agents.
  9. The dura is closed or a dural graft is placed if a decompression was required.
  10. The bone flap is either replaced and secured with titanium plates and screws (craniotomy) or left out for future replacement (craniectomy).
  11. The scalp is closed in layers with sutures or staples, and a subgaleal drain may be placed.

Coding Guidelines

  • Code 61312 is specific to the supratentorial region; for infratentorial (posterior fossa) hematoma evacuation, use 61313.
  • The code covers both craniotomy (replacement of bone flap) and craniectomy (bone flap not replaced).
  • Initial burr holes used to create the craniotomy/craniectomy are bundled and not reported separately via 61154.
  • If an intracerebral hematoma (within the brain parenchyma) is evacuated during the same session, see code 61314.
  • If a separate cranioplasty (62140 or 62141) is performed during a later session to replace the bone flap, it is reported separately.
  • Do not report 61312 in conjunction with 61314 or 61315 unless performed at different anatomical sites or for distinct pathologies requiring separate approaches.

Associated ICD-10 Codes