Sudural Haemorrhage

Question 1

Definition of SDH

Answer 1

A collection of blood between the dural and arachnoid layers of the brain

Question 2

Aetiology of SDH

Answer 2

• The primary cause for both acute and chronic SDH is TRAUMA
◦ Less commonly, they’re associated with rupture of cerebral aneurysm or vascular malformation

Question 3

Pathophysiology of SDH

Answer 3

• Typically result from torsional or shear forces that disrupt the cortical veins. Venous= low pressure
• As the volume of the haematoma increases, the brain parenchyma is compressed and a midline shift may occur.
• The raised ICP can cause herniation and coning if not treated.
◦ The raised ICP can also limit cerebral blood flow and hence ischaemic injury would occur

• Chronic SDH take longer to display symptoms due to brain atrophy allowing for the haematoma to grow more before causing symptoms

Question 4

History and Examination of SDH

Answer 4

• Evidence of trauma: scalp and face abrasions, lacerations, ecchymosis etc
• Headache: can be a sign of increased ICP
• Confusion: may be a sign of raised ICP
• Loss of consciousness/decreased alertness: sign of midline shift
• Fluctuating consciousness/Insidious neurological deficit: can indicate growing of haematoma
• Diminished eye, verbal and/or motor response
• Nausea/vomiting
• Occurs late, often >1 month after injury
• Hemiparesis
• Seizures

Question 5

Risk factors of SDH

Answer 5

• Recent trauma
• Coagulopathy and anticoagulant use
• Advanced age

Question 6

Investigations for SDH

Answer 6

• Non-contrast CT scan: can show the fluid collection and maybe midline shift (compresses ventricles). Would have a ‘crescent’ shape
• May do MRI

Question 7

Treatment for SDH if ‘<10mm size, midline shift <5mm non-expansile without significant neuro dysfunction’:

Answer 7

1) Observation, monitoring and follow up imaging: Monitor GCS, pupils and ICP. Follow up CT 2-3 weeks after discharge

+Prophylactic Antiepileptics: Phenytoin generally given for 7 days

+Correct coagulopathy: Stop anticoagulation

Question 8

Treatment for SDH if ‘
>10mm size or midline shift, >5mm or expansile or significant neuro dysfunction’:

Answer 8

1) Surgery: Is indicated for expanding haematoma and/or if causing neuro deficit. May need burr hole craniotomy with irrigation
+ Monitoring: GCS, ICP

+ Prophylactic antiepileptics: Given for 7 days

+ Stop anti-coagulation

+address cause of the trauma (e.g falls, abuse etc)

Question 9

Prevention of SDH

Answer 9

Seatbelts and helmets should be used. Patients on anticoagulation should use walking aids if required
After SDH, patients should avoid antithrombotics or anticoagulants unless very much needed

Question 10

Complications of SDH

Answer 10

• Epilepsy: high risk of post-traumatic epilepsy
• Neurological deficits

Question 11

Prognosis of SDH

Answer 11

Poor prognostic outcomes if older age, greater severity, low GCS, midline shift, raised ICP.