Subdural hemorrhage: Difference between revisions

(link)
Line 14: Line 14:


==Workup==
==Workup==
[[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]]
{{Head trauma workup}}
{{Head trauma workup}}
* Head CT is the gold standard
* Head CT is the gold standard
Line 19: Line 20:
** Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
** Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
** Contrasted studies are useful in distinguishing acute, subacute, and chronic
** Contrasted studies are useful in distinguishing acute, subacute, and chronic


==Differential Diagnosis==
==Differential Diagnosis==

Revision as of 22:17, 16 March 2015

Background

  • Can present as acute (<14 days) and chronic (>14 days)
  • Both types are caused by sudden acceleration-deceleration of the brain with resultant shearing of the bridging veins.
    • Blood pools between the dura mater and arachnoid
  • Patients with extreme atrophy are at increased risk (elderly, alcoholics)
    • Patients less than 2 years old are also at increased risk
  • SDH are often associated with other brain injuries


Diagnosis

  • Patients with acute SDH generally will present unconscious after a severe trauma
  • Patients with chronic SDH generally present with altered mental status or vague complaints
  • High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity

Workup

Large left-sided frontal-parietal subdural hematoma with associated midline shift.

Workup

  • Consider head CT (rule out intracranial hemorrhage)
    • Use validated decision rule to determine need
    • Avoid CT in patients with minor head injury who are at low risk based on validated decision rules.[1]
  • Consider cervical and/or facial CT
  • Head CT is the gold standard
    • Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance
    • Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
    • Contrasted studies are useful in distinguishing acute, subacute, and chronic

Differential Diagnosis

Intracranial Hemorrhage Types

Management

  • Emergent neurosurgical evacuation
    • Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)[2]
  • Management of ICP
    • Head of bed to 30 degrees
    • Short-term use of hyperventilation
    • Hyperosmolar agents (Mannitol, 3% saline)
  • Reversal of anticoagulation
  • Trephination (Burr holes)

Disposition

  • Admission to NS or trauma surgery
  • Considered high level of care for q1-2hr neuro checks

See Also

External Links

References

  1. Choosing wisely ACEP
  2. Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24