Subdural Haemorrhage

Question 1

Definition

Answer 1

· A collection of blood that develops between the surface of the brain and the dura mater

· Classification
o ACUTE: < 72 hrs
o SUBACUTE: 3- 20 days
o CHRONIC: > 3 weeks

Question 2

Aetiology

Answer 2

· Trauma (usually due to rapid acceleration and deceleration of the brain)

Question 3

Epidemiology

Answer 3

· Acute - younger patients/associated with major trauma

· MORE COMMON than extradural haemorrhage

· Chronic - more common in the ELDERLY

Question 4

Presenting symptoms

Answer 4

· Acute
o History of TRAUMA with head injury
o Reduced conscious level

· Subacute
o Worsening headache 7-14 days after injury
o Altered mental state

· Chronic
o Headache
o Confusion
o Cognitive impairment
o Psychiatric symptoms
o Gait deterioration
o Focal weakness
o Seizures

Question 5

Signs on physical examination

Answer 5

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

· Chronic
o Neurological examination may be NORMAL
o Focal neurological signs (e.g. 3rd nerve palsy)

Question 6

Investigations

Answer 6

CT head

MRI brain - higher sensitivity than CT

Question 7

Management plan

Answer 7

· ACUTE
o ALS protocol
o Watch out for cervical spine injury
o If raised ICP consider osmotic diuresis

· Conservative - if small

· Surgical
o Prompt Burr hole or craniotomy

· Chronic
o If symptomatic - Burr hole or craniotomy and drainage

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

Question 8

Possible complications

Answer 8

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

Question 9

Prognosis

Answer 9

· Acute
o Underlying brain injury will affect function

· Chronic
o Better outcome than subdural haemorrhages
o Lower incidence of underlying brain injury