Subdural Haemorrhage Flashcards
What is a subdural haemorrhage?
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What is the aetiology of a subdural haemorrhage?
- Trauma causing rapid acceleration and deceleration of the brain results inn shearing forces which tear veins (bridging veins) that travel from the dura to the cortex - Bleeding occurs between the dura and arachnoid membranes - In children, non- accidental injury should always be considered
What is the epidemiology of subdural haemorrhage?
- Acute: Tend to occur in younger patients/associated with major trauma. More common than extradural haemorrhage - Chronic: More common in elderly
What are the presenting symptoms of an acute subdural haemorrhage?
- History of trauma with head injury - Patient has decreased conscious level
What are the presenting symptoms of a subacute subdural haemorrhage?
- Worsening headaches 7-14 days after injury - Altered mental status
What are the presenting symptoms of a chronic subdural haemorrhage?
- Can present with headache, confusion, cognitive impairment, psychiatric symptoms, gait deterioration, focal weakness, seizures - May not be history of fall or trauma, hence have low index of suspicion especially in the elderly and alcoholics
What are the signs of an acute subdural haemorrhage on examination?
- Decreased GCS - With large haematomas resulting in midline shift, and ipsilateral fixed dilated pupil may be seen (compression of the ipsilateral third nerve parasympathetic fibres) - Pressure on brainstem: reduced consciousness, bradycardia
What are the signs of a chronic subdural haemorrhage on examination?
- Neurological examination may be normal - May be focal neurological signs (III or VI nerve dysfunction, papilloedema, hemiparesis or reflex asymmetry)
What are the investigations for a subdural haemorrhage?
- CT head: Crescent or sickle shaped mass, concave over brain surface (extradural is lentiform shape). CT appearance changes with time. Acute subdurals are hyperdense, becoming isodense over 1-3 weeks (such as presence may be inferred from signs such as effacement of sulci, midline shift, ventricular compression and obliteration of basal cisterns) and chronic subdurals are hypodense (approaching that of CSF) - MRI brain: has higher sensitivity especially for isodense or small SDHs
How is an acute subdural haemorrhage managed?
- ALS protocol with priorities of cervical spin control and ABC - With a head injury, significant risk of cervical spine injury - Disability: GCS, pupillary reactivity - If signs of raised ICP, head elevation and consider osmotic diuresis with mannitol and/or hyperventilation. - Once stabilised, obtain CT head
When is conservative management for a subdural haemorrhage opted for?
If small and minimal midline shift (SDH less than 10mm thickness and midline shift less than 5mm
What is the surgical management for a subdural haemorrhage?
- Prompt Burr hole or craniotomy and evacuation for symptomatic subdurals, more than 10mm, with more than 5mm midline shift (better outcome if within 4h) - ICP monitoring devices may be placed
How are chronic subdural haemorrhages managed?
- If symptomatic or if there is mass effect on imagine, surgical treatment with Burr hole or cranitomoy and drainage. - Asymptomatic SDH without significant mass effect is best managed conservatively with serial imaging to monitor for spontaneous resorption - Haematomas that have not fully liquefied may require craniotomy and membranectomy
How are subdural haemorrhages managed in children?
Younger children may be treated by percutaneous aspiration via an open fontanelle or if this fails, placement of a subdural to peritoneal shunt
What are the possible complications of a subdural haemorrhage?
- Raised ICP, cerebral oedema pre-disposing to secondary ischaemic brain damage, mass effect (transtentorial or uncal herniation) - Post-op: Seizures are relatively common, recurrence (up to 33% for SDH), intracerebral haemorrhage, subdural empyema, brain abscess or meningitis, tension pneumocephalus
