Subdural haemorrhage

Question 1

define:

Answer 1

A collection of blood that develops between a surface of the brain and the dura matter.

Acute < 72 hrs
Subacute - 3 -20 days
Chronic > 3weeks

Question 2

Aetiology:

Answer 2

Trauma (due to acceleration and deceleration of the brain)

Weakness in the bridging veins in the subdural space

Question 3

Risk factors:

Answer 3

Falls (epileptics and alcoholics)
Low ICP
Dural metastases 
Age (brain atrophy leads to weaker bridging veins)
Anticoagulation

Question 4

Symptoms of acute subdural haemorrhage:

Answer 4

o History of TRAUMA with head injury

o Reduced conscious level

Question 5

Symptoms of subacute haemorrhage:

Answer 5

o Worsening headache 7-14 days after injury

o Altered mental state

Question 6

Symptoms of chronic haemorrhage:

Answer 6

o	Headache
o	Confusion
o	Cognitive impairment 
o	Gait deterioration 
o	Focal weakness 
o	Seizures 
o	Sleepiness

Question 7

Signs of acute haemorrhage:

Answer 7

o Reduced GCS
o Ipsilateral fixed dilated pupil (if a large haematoma cause a midline shift)
o Pressure on brainstem –> reduced consciousness + bradycardia

Question 8

Signs of chronic haemorrhage:

Answer 8

o Neurological examination may be NORMAL

o Focal neurological signs (e.g. 3rd nerve palsy)

Question 9

Investigations:

Answer 9

• CT Head
• MRI Brain - higher sensitivity than CT
• Will show clot +/- midline shift
• Look for crescent shaped collection of blood over 1 hemisphere (concave) – the sickle shape differentiates subdural blood from extradural haemorrhage (lens shaped)

Question 10

Management of acute haemorrhage:

Answer 10

o ALS protocol
o Watch out for cervical spine injury
o If raised ICP consider osmotic diuresis
• Conservative - if small
• Surgical – for irrigation/evacuation
o Burr twist drill and burr hole craniostomy – 1st line
o Craniotomy – 2nd line

Question 11

Management of chronic haemorrhage:

Answer 11

o If symptomatic - Burr hole or craniotomy and drainage

• Assess any causes of the trauma

Question 12

Management in children:

Answer 12

o Younger children may be treated with percutaneous aspiration via an open fontanelle

Question 13

Complications:

Answer 13

• Raised ICP
• Cerebral oedema
• Herniation
• Post-Op - seizures, recurrence, intracerebral haemorrhage, brain abscess, meningitis, tension pneumocephalus

Question 14

Prognosis:

Answer 14

• Acute
o Underlying brain injury will affect function
• Chronic
o Better outcome than acute subdural haemorrhages
o Lower incidence of underlying brain injury