Subdural hemorrhage

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

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.
• 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

• Intra-axial
  • Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
  • Traumatic intracerebral hemorrhage
• Extra-axial
  • Epidural hemorrhage
  • Subdural hemorrhage
  • Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)

Management

• Emergent neurosurgical evacuation
  • Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)
• 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

• Intracranial Hemorrhage (Main)
• Head Trauma

External Links

• SDH Radiographs