Subdural Hematoma

Aka: Subdural Hematoma, Subdural Hemorrhage

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II. Epidemiology

  1. Represents 30% of Traumatic Intracranial Hemorrhage causes
    1. Six times more common than Epidural Hematoma

III. Risk Factors

  1. Anticoagulation (e.g. Warfarin)
  2. Brain atrophy predisposes to sudural Hematoma (even with minor Head Trauma)
    1. Elderly
    2. Alcoholism

IV. Pathophysiology

  1. Cranial Trauma results in Subdural Hemorrhage
  2. Tear of bridging veins between Dura Mater and the arachnoid membrane on the surface of the brain
    1. Sudden acceleration-deceleration is typical cause
  3. Subdural Hematoma accumulation exerts pressure on the brain
    1. Results in neurologic tissue ischemia
    2. May progress to Cerebral Herniation (esp. acute Subdural Hematoma)

V. Precautions: Acute Subdural Hematoma

  1. Acute Subdural Hematomas are vastly different than chronic Subdural Hematoma
  2. Acute Subdural Hematoma has a 60-80% mortality rate
  3. Requires rapid assessment and management (surgical decompression)

VI. Causes: Acute Subdural Hematoma

  1. Severe Closed Head Injury
  2. Rapid Deceleration Injury

VII. Associated Conditions: Acute Subdural Hematoma

  1. Comorbid Brain Contusion

VIII. Symptoms

  1. Acute Subdural Hematoma (Rapid progression of symptoms)
    1. Headache
    2. Irritability
  2. Chronic Subdural Hematoma (Insidious symptom progression)
    1. Intermittent Headache
    2. Variable levels of Decreased Level of Consciousness

IX. Signs

  1. Acute Subdural Hematoma (<24 hours)
    1. Fluctuating levels of consciousness
    2. Dilated pupils
    3. Hemiplegia
    4. Hyperreflexia
    5. Babinski's Sign
    6. Convulsions
  2. Subacute (24 hours to 2 weeks)
  3. Chronic Subdural Hematoma (>2 weeks)
    1. Progressively impaired intellect
    2. Agitation
    3. Impulsive behavior
    4. Hemiparesis
    5. Stupor
    6. Variable Level of Consciousness

X. Imaging: CT Head

  1. Subdural Hematoma appears as crescent-shaped Hematoma
    1. As this is below the dura, the Subdural Hematoma follows the surface of the brain
    2. Gyri are absent in region of Subdural Hematoma
      1. Helps identify subacute Subdural Hematoma which is isodense and more difficult to distinguish
  2. Appearance varies based on timing
    1. Acute: White blood collection
    2. Subacute: Isodense blood collection (may be subtle)
    3. Chronic: Dark blood collection

XI. Labs: Cerebrospinal fluid

  1. Increased CSF Opening Pressure
  2. CSF Protein increased
  3. CSF Bloody or xanthochromic fluid

XII. Diagnostic Testing: EEG

  1. Localized disturbance

XIII. Management

  1. Admit all patients with chronic or acute Subdural Hematoma (SDH)
  2. Anticoagulation and antiplatelet agent use predisposes to subdural expansion
  3. Manage systolic Blood Pressure, targets per neurosurgery, but typically <180 mmHg
  4. Surgical decompression
    1. Indications
      1. Subdural thickness >10 mm
      2. Midline shift >5 mm
      3. Glasgow Coma Scale decreases >2 points from initial injury
      4. Cerebral Herniation findings (e.g. acute Anisocoria)
    2. Over age 65 years old, are unlikely to need surgical intervention if
      1. Midline shift <=1 mm
      2. Width <= 10 mm
      3. Evans (2015) Injury 46(91): 76-9 [PubMed]
    3. Emergency surgical decompression if acute Subdural Hematoma with signs of Herniation
      1. See Skull Trephination

XIV. Prognosis

  1. Worse prognosis than Epidural Hematoma (given decompression)
    1. Subdural Hematomas are associated with greater brain parenchymal injury than Epidural Hematomas
  2. Predictors of worse prognosis
    1. Loss of consciousness at time of Closed Head Injury (associated with Diffuse Axonal Injury)
    2. Low initial glasgow coma score (GCS score)
    3. Increased Intracranial Pressure
    4. High injury mechanism

XV. References

  1. Abuguyan (2024) Crit Dec Emerg Med 38(7): 4-11
  2. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  3. Marcolini and Swaminathan in Swadron (2023) EM:Rap 23(5): 13-14

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Related Studies

Ontology: Hematoma, Subdural (C0018946)

Definition (SCTSPA) Sangrado hacia el espacio subdural intracraneal
Definition (SCTSPA) Colección de sangre extravascular en el espacio subdural intracraneal
Definition (SNOMEDCT_US) Bleeding into the intracranial subdural space
Definition (SNOMEDCT_US) A collection of extravascular blood in the intracranial subdural space
Definition (NCI_FDA) Cerebral hemorrhage into the subdural space. See also Stroke Syndrome.
Definition (NCI) Cerebral hemorrhage into the subdural space. See also Stroke Syndrome.
Definition (MSH) Accumulation of blood in the SUBDURAL SPACE between the DURA MATER and the arachnoidal layer of the MENINGES. This condition primarily occurs over the surface of a CEREBRAL HEMISPHERE, but may develop in the spinal canal (HEMATOMA, SUBDURAL, SPINAL). Subdural hematoma can be classified as the acute or the chronic form, with immediate or delayed symptom onset, respectively. Symptoms may include loss of consciousness, severe HEADACHE, and deteriorating mental status.
Concepts Pathologic Function (T046)
MSH D006408
ICD9 432.1
SnomedCT 415649003, 35486000, 95453001, 155393009, 313305008
English Hematomas, Subdural, Subdural Hematomas, HAEMORRHAGE SUBDURAL, HEMORRHAGE SUBDURAL, SUBDURAL HAEMATOMA, SUBDURAL HEMATOMA, Subdural Hematoma, Subdural Hemorrhage, Subdural haemorrhage NOS (disorder), subdural hematoma (diagnosis), subdural hematoma, Haemorrhage subdural, Hematoma subdural, Subdural hematonia, Hemorrhage subdural, Hemorrhage, Subdural, Hemorrhages, Subdural, Subdural Hemorrhages, Hematoma, Subdural [Disease/Finding], subdural hematoma (SDH), subdural bleeding, sdh, subdural hemorrhages, Haemorrhage;subdural, subdural haematoma, subdural hematomas, Hematoma, Subdural, Subdural intracranial hemorrhage, Subdural intracranial hematoma (disorder), Subdural intracranial hematoma, Subdural hematoma (disorder), Subdural intracranial haemorrhage, Subdural intracranial hemorrhage (disorder), Subdural intracranial haematoma, Subdural bleeding, subdural hemorrhage (diagnosis), subdural hemorrhage, Subdural hemorrhage (disorder), Subdural hemorrhage NOS, Subdural haematoma (disorder), Haematoma subdural, Subdural hemorrhage NOS (disorder), Subdural haemorrhage NOS, SUBDURAL HEMORRHAGE, HEMORRHAGE, SUBDURAL, Subdural hemorrhage, Subdural hematoma, Subdural haematoma, Subdural haemorrhage, SDH - Subdural haematoma, SDH - Subdural hematoma, hematoma; subdural, hemorrhage; subdural, subdural; hematoma, subdural; hemorrhage, Subdural hematoma, NOS, Subdural hemorrhage, NOS, Subdural hemorrhage [dup] (disorder), Hemorrhage;subdural, subdural haemorrhage
French HEMATOME SOUS-DURAL, Hématonie sous-durale, Hématomes subduraux, Hématome sous-dural, Hématome subdural, HEMORRAGIE SOUS-DURALE, Hématomes sous-duraux, Saignement sous-dural, Hémorragie sous-durale, HSD (Hématome Sous-Dural)
Portuguese HEMATOMA SUBDURAL, HEMORRAGIA SUBDURAL, Sangramento subdural, Hematoma subdural, Hemorragia subdural, Hematoma Subdural, Hemorragia Subdural
Spanish HEMATOMA SUBDURAL, HEMORRAGIA SUBDURAL, Sangrado subdural, hematoma subdural intracraneal, hemorragia subdural, hemorragia subdural intracraneal, hematoma subdural, hematoma subdural intracraneal (trastorno), hemorragia subdural (trastorno), hematoma subdural (trastorno), hemorragia subdural intracraneal (trastorno), hemorragia subdural, SAI (trastorno), hemorragia subdural, SAI, Hematoma subdural, Hemorragia subdural, Hematoma Subdural, Hemorragia Subdural
Dutch hematoom subduraal, subdurale bloeding, bloeding subduraal, hemorragie subduraal, bloeding; subduraal, hematoom; subduraal, subduraal; bloeding, subduraal; hematoom, subduraal hematoom, subdurale hemorragie, Bloeding, subduraal, Hematoom, subduraal, Subduraal hematoom
German Haematom subdural, Blutung subdural, BLUTUNG SUBDURAL, HAEMATOM SUBDURAL, subdurale Blutung, subdurales Haematom, Blutung, subdurale, Subduralblutung, Hämatom, subdurales, Hämorrhagie, subdurale, Subdurales Hämatom
Italian Emorragia all'interno dello spazio subdurale, Emorragia, subdurale, Emorragia dello spazio subdurale, Emorragia subdurale, Sanguinamento subdurale, Ematoma subdurale
Japanese 硬膜下出血, ｺｳﾏｸｶｼｭｯｹﾂ, ｺｳﾏｸｶｹｯｼｭ, 血腫-硬膜下, 硬膜下血腫
Swedish Subduralblödning
Czech hematom subdurální, Subdurální krvácení, Subdurální hematom, Subdurální hemoragie
Finnish Subduraalihematooma
Russian GEMORRAGIIA SUBDURAL'NAIA, GEMATOMA SUBDURAL'NAIA, ГЕМАТОМА СУБДУРАЛЬНАЯ, ГЕМОРРАГИЯ СУБДУРАЛЬНАЯ
Croatian HEMATOM, SUBDURALNI
Polish Krwiak podtwardówkowy
Hungarian Subduralis vérzés, Subduralis haematoma
Norwegian Subduralt hematom, Subduralblødning
Derived from the NIH UMLS (Unified Medical Language System)

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