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Subdural hemorrhage
From WikEM
Contents
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
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
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
Evaluation
- 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
- 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
- ↑ Choosing wisely ACEP
- ↑ Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24
- ↑ 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
- ↑ 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.
