Subdural Haemorrhage

Question 1

Define subdural haemorrhage (Acute and chronic)

Answer 1

Collection between the dura mater and the surface (arachnoid covering) of the brain

Acute: <3 days old, diffusely hyperdense
Subacute: 3-21 days old, heterogeneously hyperdense/isodense
Chronic: >21 days old, diffusely hypodense

Question 2

What are the causes of subdural haemorrhage

Answer 2

Torsional or shear force causing disruption of bridging cortical veins as they cross the subdural space, emptying into dural venous sinuses
- Non-accidental injury caused by shaking and/or direct trauma in infants and toddlers (shaken-baby syndrome)
- Fall from a considerable height
- Brain shrinkage or overdrainage of hydrocephalus
- Ventriculoperitoneal shunts
- Cerebral aneurysm rupture
- Vascular malformation: arteriovenous malformation or dural fistula
- Rare: cerebral hypotension and malignancy
- Coagulopathy and anticoagulant use

Question 3

What are the symptoms of subdural haemorrhage

Answer 3

Headache (Gradual onset, Continuous/constant, worsening after injury)
Raised ICP: nausea and vomiting, early morning headache
Drowsiness
Personality change
Loss of bowel and bladder continence (cerebral dysfunction)
Basilar skull fracture: Otorrhoea, rhinorrhoea

Question 4

What are the features of shaken-baby syndrome

Answer 4

Subdural haemorrhage
Retinal haemorrhages
Encephalitis

Question 5

What are the signs of subdural haemorrhage on examination

Answer 5

Acute: reduced GCS, ipsilateral fixed dilated pupil (midline shift, CNIII compression), bradycardia (brainstem)

Chronic: cognitive impairment, gait deterioration, focal weakness, seizures, focal neurological signs

Question 6

What investigations should be done for subdural haematoma

Answer 6

Bloods: FBC, clotting studies, blood cultures, U&Es, LFTs

Other
- CT head: Crescent shape | Acute: HYPERdense → isodense over 1-3 weeks | Chronic: HYPOdense (similar to CSF)
- MRI brain
- Plain skull x-ray
- Skeletal survey (Suspicion of NAI): rib fractures, skull fractures, long bone and metaphyseal fractures

Question 7

What is the management for subdural haemorrhage

Answer 7

1. Admit and Contact neurosurgeons
2. Advise bed rest
3. Analgesia: paracetamol, codeine, tramadol, morphine, oxycodone (Avoid aspirin and NSAIDs)
4. Stool softener and anti-emetic
5. Maintain normovolaemia and avoid hypovolaemia
6. Compression stockings and intermittent compression

<10mm: observe, mointor
>10mm/midline shift: Burr hole or craniotomy

Question 8

What are the complications for subdural haemorrhage

Answer 8

Neurological deficits e.g. raised ICP, cerebral oedema
Coma
Stroke
Epilepsy
Recurrence of subdural haematoma post-op (33%)
Neuropsychiatric problems: cognitive impairment e.g. mood, memory
Macrocephalus
Chronic hydrocephalus
Neck injury → Spinal cord injury
- More common in high impact trauma e.g. high-speed road traffic collisions
- Most common neck injury: fracture of the upper two cervical vertebrae
Spinal cord injury without bony damage (SCIWORA)