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Here’s a sneaky hematoma bulging following a craniotomy and excision of the dura mater! A subdural hematoma results in blood gathering between the inner layer of the dura mater and the arachnoid mater. It commonly happens in the settings of severe head injury or elderly patient taking anticoagulants, resulting from tears in bridging veins which cross the subdural space. As blood builds up, it causes an increase in intracranial pressure which may cause compression and damage to the brain tissue. The bleeding fills the brain area, compressing the brain tissue. All the built up pressure due to the intra-cranial bleeding pushes the hematoma out once craniotomy is done - hence why it's bulging. After performing a craniotomy the surgeon pulls back the top of the head to reveal the bloodied dura mater. The dura mater is cut and beneath lies the thick pool of blood, the subdural hematoma. Photo by @rpaglioli