Subdural hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
* Can present as acute (<14 days) and chronic (>14 days) | *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. | *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 | **Blood pools between the dura mater and arachnoid | ||
* 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 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 DDX}} | |||
==Diagnosis== | ==Diagnosis== | ||
[[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 | ||
** 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 | ||
** Contrasted studies are useful in distinguishing acute, subacute, and chronic | **Contrasted studies are useful in distinguishing acute, subacute, and chronic | ||
==Management== | ==Management== | ||
* 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> | **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> | ||
* Management of ICP | *Management of 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]], 3% saline) | ||
* [[Coagulopathy (Main)|Reversal of anticoagulation]] | *[[Coagulopathy (Main)|Reversal of anticoagulation]] | ||
* | *Emergency Department [[Burr hole]], if indicated | ||
==Disposition== | ==Disposition== | ||
*Admission to NS or trauma surgery | *Admission to NS or trauma surgery | ||
==See Also== | ==See Also== | ||
Revision as of 04:38, 23 July 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
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
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
Diagnosis
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
- 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
- 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