Difference between revisions of "Subdural hemorrhage"

(Background)
 
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*Patients with extreme atrophy are at increased risk (elderly, alcoholics)
 
*Patients with extreme atrophy are at increased risk (elderly, alcoholics)
 
**Patients less than 2 years old are also at increased risk
 
**Patients less than 2 years old are also at increased risk
*SDH are often associated with other brain injuries
+
*SDH are often associated with other [[TBI|brain injuries]]
  
 
==Clinical Features==
 
==Clinical Features==
*Patients with acute SDH generally will present unconscious after a severe trauma
+
*Patients with acute SDH generally will present unconscious after a severe [[head trauma|trauma]]
*Patients with chronic SDH generally present with altered mental status or vague complaints
+
*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
 
*High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity
  
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[[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]]
 
[[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]]
 
{{Head trauma workup}}
 
{{Head trauma workup}}
*Noncontrast CT Brain is the gold standard
+
*Noncontrast [[head CT|CT]] brain is the gold standard
 
**Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance
 
**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
 
**Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
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*Emergent neurosurgical evacuation
 
*Emergent neurosurgical evacuation
 
**Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)<ref>Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24</ref> <ref>Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9</ref>
 
**Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)<ref>Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24</ref> <ref>Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9</ref>
*Management of ICP
+
*Management of [[elevated ICP|ICP]]
 
**Head of bed to 30 degrees
 
**Head of bed to 30 degrees
 
**Short-term use of hyperventilation  
 
**Short-term use of hyperventilation  
**Hyperosmolar agents ([[Mannitol]], 3% saline)
+
**Hyperosmolar agents ([[Mannitol]], [[hypertonic saline|3% saline]])
*[[Coagulopathy (Main)|Reversal of anticoagulation]]
+
*[[Anticoagulant reversal|Reversal of anticoagulation]]
 
*Treat and prevent hypotension and hypoxia
 
*Treat and prevent hypotension and hypoxia
 
**Associated with significantly increased mortality<ref>Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.</ref>
 
**Associated with significantly increased mortality<ref>Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.</ref>
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==Disposition==
 
==Disposition==
*Admission to NS or trauma surgery
+
*Admission to neurosurgery or trauma surgery
  
 
==See Also==
 
==See Also==

Latest revision as of 16:21, 3 October 2019

Background

Anatomy of the meninges
  • 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

Clinical Features

  • 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

Differential Diagnosis

Intracranial Hemorrhage Types

Evaluation

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
  • Noncontrast CT brain 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

Management

  • See Head trauma (main)
  • Emergent neurosurgical evacuation
    • Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)[2] [3]
  • Management of ICP
    • Head of bed to 30 degrees
    • Short-term use of hyperventilation
    • Hyperosmolar agents (Mannitol, 3% saline)
  • Reversal of anticoagulation
  • Treat and prevent hypotension and hypoxia
    • Associated with significantly increased mortality[4]
  • Emergency Department Burr hole, if indicated

Disposition

  • Admission to neurosurgery or trauma surgery

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
  3. Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9
  4. Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.