Subdural haemorrhage (A&E)

Question 1

Define subdural haemorrhage.

Answer 1

Collection of blood between the dural and arachnoid coverings of the brain

Question 2

What blood vessel is typically ruptured in subdural haemorrhage?

Answer 2

Bridging veins between cortex and venous sinus

Question 3

What happens as the volume of a subdural haemorrhage increases?

Answer 3

Brain parenchyma is compressed and displaced, and the ICP may rise and cause herniation

Question 4

What is subdural haemorrhage usually due to?

Answer 4

Trauma (delayed onset - trauma may have been up to 9 months ago) - usually due to acceleration and deceleration of the brain

Question 5

What are the three types of subdural haemorrhage?

Answer 5

• acute: <3d old, hyperdense bleeding on imaging, commonly due to trauma
• subacute: 4-20d old, hyperdense bleeding on imaging
• chronic: >21d old, hypodense bleeding on imaging, typically due to rupture of veins

Question 6

What are some risk factors for subdural haemorrhage? (6)

Answer 6

• recent trauma e.g. falls (epileptics, alcoholics)
• anticoagulant use / coagulopathy
• alcohol use
• age >65y (brain atrophy –> bridging veins between cortex and venous sinuses vulnerable)
• low ICP
• dural metastases

Question 7

What demographic does subdural haemorrhage happen most in? (2)

Answer 7

• M>F
• older people >65

Question 8

What are the general clinical features of subdural haemorrhage? (7)

Answer 8

• can present several weeks after initial head injury
• gradual continuous headaches = sign of raised ICP
• nausea/vomiting
• fluctuating confusion/consciousness/loss of consciousness
• diminished eye, verbal and motor response (low GCS)
• seizures
• lucid interval

Question 9

How does subdural haemorrhage typically present?

Answer 9

Several weeks to month progressive Hx of either confusion, reduced consciousness or neurological deficit

Question 10

How does acute subdural haemorrhage present? (2)

Answer 10

• Hx of trauma with head injury (<3d)
• reduced conscious level

Question 11

How does subacute subdural haemorrhage present? (3)

Answer 11

• worsening headache 7-14d after injury
• altered mental state
• nausea and vomiting

Question 12

How does chronic subdural haemorrhage present? (7)

Answer 12

• headache
• confusion
• cognitive impairment
• gait deterioration
• focal weakness
• seizures
• sleepiness

Question 13

What might you see on examination in acute subdural haemorrhage? (3)

Answer 13

• reduced GCS
• ipsilateral fixed dilated pupil (if large haematoma causes midline shift)
• pressure on brainstem –> reduced consciousness + bradycardia

Question 14

What might you see on examination in chronic subdural haemorrhage? (6)

Answer 14

• neurological examination may be NORMAL
• focal neurological signs e.g. CN III palsy
• diminished eye, verbal and motor responses
• seizure
• loss of bowel and bladder continence
• basilar skull fracture - otorrhoea or rhinorrhoea

Question 15

What is the first-line investigation for subdural haemorrhage?

Answer 15

Non-contrast CT head

Question 16

What would we see in non-contrast CT head in subdural haemorrhage?

Answer 16

• crescent-shaped bleed not limited by suture lines
  
  • EPIdural haemorrhage –> PIE –> lemon = this must be opposite –> banana
• can see clot and midline shift
• in acute/subacute - HYPERdense bleed as it is more recent = brighter
• in chronic - HYPOdense bleed as it is older = darker

Question 17

What is the second-line investigation done for subdural haemorrhage (after non-contrast CT head)?

Answer 17

MRI head if CT head is inconclusive

Question 18

What are some differential diagnoses for subdural haemorrhage? (6)

Answer 18

• extradural haemorrhage - lucid interval, lenticular (lemon) lesion on CT
• intracerebral haematoma/haemorrhage
• diffuse axonal injury
• stroke
• seizure - lingering Todd’s paralysis up to 48h after
• substance abuse

Question 19

How would you manage an acute, small, non-complicated subdural haemorrhage? (3)

(<10mm size, midline shift<5mm)

Answer 19

• stop anticoagulants/antiplatelets
• start prophylactic antiepileptics (phenytoin or levetiracetam)
• observation

Question 20

How would you manage a subdural haemorrhage >10mm depending on if it is acute or chronic? (2)

Answer 20

• acute –> decompressive craniotomy
• chronic –> burr hole evacuation

Question 21

How would you manage a chronic subdural haemorrhage? (3)

Answer 21

• stop anticoagulants/antiplatelets
• start antiepileptics (phenytoin or levetiracetam)
• elective surgery

Question 22

What else do we monitor in subdural haemorrhage?

Answer 22

ICP - try to reduce: (do not memorise below)

• raise head to 30 degrees
• reverse Trendelenberg position if spinal injury
• hyperventilation
• hyperosmolar therapy
• mannitol
• pentobarbital coma
• hypothermia
• decompressive hemicraniectomy

Question 23

How do we manage subdural haemorrhage in children?

Answer 23

Younger children may be treated with percutaneous aspiration via open fontanelle

Question 24

What are some complications of subdural haemorrhage? (7)

Answer 24

• epilepsy
• neurological deficits
• coma
• raised ICP
• cerebral oedema
• herniation
• post-op: seizures, recurrence, intracerebral haemorrhage, brain abscess, meningitis, tension pneumocephalus

Question 25

Describe the prognosis of subdural haemorrhage.

Answer 25

• acute - higher likelihood of underlying parenchymal injury –> associated with worse prognosis than acute extradural haemorrhage
• chronic - better than acute SDH but higher mortality increases with age