Subdural haemorrhage (A&E) Flashcards
Define subdural haemorrhage.
Collection of blood between the dural and arachnoid coverings of the brain
What blood vessel is typically ruptured in subdural haemorrhage?
Bridging veins between cortex and venous sinus
What happens as the volume of a subdural haemorrhage increases?
Brain parenchyma is compressed and displaced, and the ICP may rise and cause herniation
What is subdural haemorrhage usually due to?
Trauma (delayed onset - trauma may have been up to 9 months ago) - usually due to acceleration and deceleration of the brain
What are the three types of subdural haemorrhage?
- 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
What are some risk factors for subdural haemorrhage? (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
What demographic does subdural haemorrhage happen most in? (2)
- M>F
- older people >65
What are the general clinical features of subdural haemorrhage? (6)
- 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
How does subdural haemorrhage typically present?
Several weeks to month progressive Hx of either confusion, reduced consciousness or neurological deficit
How does acute subdural haemorrhage present? (2)
- Hx of trauma with head injury (<3d)
- reduced conscious level
How does subacute subdural haemorrhage present? (3)
- worsening headache 7-14d after injury
- altered mental state
- nausea and vomiting
How does chronic subdural haemorrhage present? (7)
- headache
- confusion
- cognitive impairment
- gait deterioration
- focal weakness
- seizures
- sleepiness
What might you see on examination in acute subdural haemorrhage? (3)
- reduced GCS
- ipsilateral fixed dilated pupil (if large haematoma causes midline shift)
- pressure on brainstem –> reduced consciousness + bradycardia
What might you see on examination in chronic subdural haemorrhage? (6)
- 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
What is the first-line investigation for subdural haemorrhage?
Non-contrast CT head
What would we see in non-contrast CT head in subdural haemorrhage?
- 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
What is the second-line investigation done for subdural haemorrhage (after non-contrast CT head)?
MRI head if CT head is inconclusive
What are some differential diagnoses for subdural haemorrhage? (6)
- 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
How would you manage an acute, small, non-complicated subdural haemorrhage? (3)
(<10mm size, midline shift<5mm)
- stop anticoagulants/antiplatelets
- start prophylactic antiepileptics (phenytoin or levetiracetam)
- observation
How would you manage a subdural haemorrhage >10mm depending on if it is acute or chronic? (2)
- acute –> decompressive craniotomy
- chronic –> burr hole evacuation
How would you manage a chronic subdural haemorrhage? (3)
- stop anticoagulants/antiplatelets
- start antiepileptics (phenytoin or levetiracetam)
- elective surgery
What else do we monitor in subdural haemorrhage?
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
How do we manage subdural haemorrhage in children?
Younger children may be treated with percutaneous aspiration via open fontanelle
What are some complications of subdural haemorrhage? (7)
- epilepsy
- neurological deficits
- coma
- raised ICP
- cerebral oedema
- herniation
- post-op: seizures, recurrence, intracerebral haemorrhage, brain abscess, meningitis, tension pneumocephalus
Describe the prognosis of subdural haemorrhage.
- 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
