Subdural hemorrhage

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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

Evaluation

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

Workup

  • Consider brain 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 NS 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.