Haemorrhagic Stroke: Subdural Flashcards
Definition
Subdural haemorrhage occurs when blood accumulates between the dura and arachnoid mater (subdural space), forming a collection known as a subdural haematoma (SDH).
Epidemiology/ Risk factors
Age: older patients = chronic SDH
MC = Px have a small brain
- alcoholics
- dementia
- babies that have suffered trauma
* making bridging veins more vulnerable *
Coagulopathy or anti coagulation medication
Aetiology
Rupture of bridging cortical vein due to shearing. Deceleration injuries and in abused children (shaken baby syndrome)
Acute = < 3 days old
- Due to trauma
Chronic = > 21 days old
- Associated with cortical atrophy e.g elderly or alcoholics
- Bridging veins are more prone to rupture with cortical atrophy
- Requires lower impact trauma compared to acute
- Because, there is cortical atrophy, subdural space is larger, these haematomas can enlarge significantly over time whilst patients remain asymptomatic
Pathophysiology
Trauma either due to deceleration, violent injury or due to dural metastases resulting in bleeding from bridging veins between the cortex + venous sinuses
Bridging veins bleeding + form a haematoma between dura + arachnoid = this reduces pressure + bleeding stops.
Days/weeks later the haematoma starts to autolyse due to the massive increase in chronic + osmotic pressure thus water is sucked into the haematoma resulting in haematoma enlarging = gradual rise in intra-cranial pressure (ICP) over many weeks
Shifting midline structures away from the side of the clot + if untreated leads to eventful tectorial herniation + coning (brain herniates through foramen magnum - causes significant damage).
Acute Subdural haemorrhage Signs
- Symptom onset within 3 days of inciting event
- May have a lucid interval
- Reduced consciousness (fluctuating GCS)
- Headaches + vomiting
- Slurred speech
- Focal neurological deficit e.g. weakness or fixed dilated pupil, CN3 palsy
- CUSHING’S TRIAD: bradycardia, widened pulse pressure + irregular breathing
- Seizures
Chronic Subdural Haemorrhage Signs
- Insidious onset usually in the elderly or alcoholics
- Progressive confusion and cognitive deficit
- Headaches and vomiting
- Focal neurological deficit e.g. weakness or fixed dilated pupils
Investigations
FIRST LINE = Non-contrast CT head: CRESCENT collection around the surface of the brain which is not limited by the suture lines of the skull unlike an extradural haemorrhage + Midline shift or herniation
- Acute = hyper-dense (bright)
- Subarachnoid = hypo-dense (dark)
Treatment
BURR HOLES + craniotomy
Non surgical = IV Mannitol to reduce ICP
Complications
Brain stem herniation