Subdural haematoma

Definition: a collection of extravasated blood between the dura mater and

arachoid mater
Epidemiology:
Risk factors: age, alcohol abuse, previous traumatic brain injury,
anticoagulation
Aetiology:
Head trauma vast majority
Aneurysm rupture 0.5-7.9% of those with SAH cause a SDH
AV malformation
Meningioma
Dural metastases
Coagulopathy
Neurosurgery
Cocaine abuse
Pathophysiology:
Subdural haematomas are caused by disruption of bridging veins between
the venous dural sinuses and brain. These veins are at increased risk of
rupture in patients with cerebral atrophy, particularly with the elderly,
dementia, alcoholism and other neurodegenerative diseases.
The majority of haematomas are formed by head trauma.
The haematoma typically reaches peak volume due to increased
intracranial pressure or direct compression by the clot itself.
Approximately 30% of subdural haematomas are caused by arterial
rupture, typically small cortical arteries.
Less commonly, low intracranial pressure can cause cerebrospinal fluid
leak, which reduces the CSF pressure and thus buoyancy of the brain. This
causes traction on the supporting structures, which can tear the bridging
veins. In addition, the low intracranial pressure causes engorgement of
cerebral veins, predisposing to rupture.
If undrained, fibrous tissue will be synthesized around the haematoma,
which may in turn calcify. Approximately 50% of subdural haematomas will
liquefy forming a hygroma (SDH devoid of blood) whilst the remainder will
remain stable.
Clinical features:
Acute:
o Presents 1-2 days after onset
o Approximately 50% of patients are in a coma from the time of injury
o Only 12-38% have the classic lucid period followed by progressive
neurological decline
Chronic:
o Presents >15 days after onset
o Manifestations are insidious and include cognitive impairment,
headaches, apathy, seizures and somnolence
o Global cognitive deficits are more common than focal deficits (e.g.
hemiparesis)
o Symptoms may fluctuate or remain constant
Diagnosis:
CT scan: acute subdural haematomas appear as crescentic hyperdense
lesions. Subacute and chronic haematomas appear as isodense/hypodense
crescentic lesions and may deform the cerebral surface. There have been
few studies investigating the sensitivity of CT scan for detection of

subdural haematomas but it appears to be quite sensitive (>91%) based

on 1980s studies.
MRI scan: more sensitive for detection of intracranial haemorrhage.
Angiography: indicated for evaluation of subdural haematomas with no
clear cause to exclude structural lesions such as aneurysms and AV
malformations.
Management:
Acute symptomatic: (medical emergency)
o Evaluation: GCS score, CT findings, neurological examination,
clinical stability, co-morbidities, age