Subdural Hematom

Asep Aminudin Aziz Pembimbing : DR.dr. M.Z. Arifin . SpBS(K)

Tn. Romlan/73 thn// 13060729/Trauma/MZ

KU : Penurunan kesadaran AK: 2 jam SMRS ketika pasien sedang berjalan didaerah Husein Bandung tiba-tiba pasien tertabrak motor dari arah belakang, sehingga pasien terjatuh dengan kepala membentur aspal. Riwayat pingsan (+), muntah (-), perdarahan telinga, hidung dan mulut (-). Pasien langsung dibawa ke emergensi RSHS Survei Primer A : Clear + C-spine control B : Bentuk dan gerak simetris, VBS kanan = kiri , RR : 20x/menit C : HR : 82x/menit , TD 120/80 mmHg D : GCS : E3M5V2 = 10 Pupil bulat anisokor ODS 3/5mm, RC +/+ Motorik : parese -/Survei Sekunder At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasar subcutis At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis

Rontgen Kepala tidak ada garis fraktur

Head CT Scan (Hasan Sadikin ,14-6-2013)

Head CT Scan :

Soft tissue swelling ar left parietooccipital et left frontal Bone discontinuity (-) Sylfian fissure compressed Sulcy and gyri compressed Hyperdense mass crescent shape at right frontotemporoparietal Ventricle and cysterns are compressed Midline shift > 5 mm to the left

Thorax x-ray:normal

Lab :

Hb HMT Leko Trombo

14.4 42 13800 193.000

GDS Na K ur cr

137 138 3.4 30 1.05

WD/

Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome frontotemporoparietal dextra (S06.5)+ vulnus laceratum at parietooccipital sinistra (S01.0) Craniotomy Evacuation

Th/

ICU Ward

Intra Operative Finding :

WD/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome temporoparietooocipital dextra (S06.5)+ vulnus laceratum at parietooccipital sinistra (S01.0) a/r ltemporoparietooccipital dextra: - Duramater intact, bluish, tensed - SDH clot 30 cc, lysis 5 cc, from Bridging vein - GCS pre op : E3M5V2 = 10 - Interval op : 10 hours

DO :

Permasalahan
Bagaimana mekanisme truma pada pasien ini karena pada pemeriksaan fisik ditemukan jejas sebelah kiri sementara pada pemeriksaan CT Scan kesan SDH sebelah kanan ? Apakah indikasi opersi pada pasien ini ? Bagaimana prosedur tindakan yang dilakukan bila ditempat pelayanan tidak terdapat CTScan

PEMBAHASAN

Anamnesis /73tahun 2 jam SMRS mengalami kecelakaan lalu lintas, terjatuh, kepala membentur aspal. Pingsan (+) Langsung ke RSHS

Resume

Pemeriksaan fisik GCS : E3M5V2 = 10 Pupil bulat an isokor ODS 3/5mm, RC +/+ , Motorik : parese -/ At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasar subcutis At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis CT scan kepala : SDH frontotemporoparietal dextra LAB: Hb: 14,4, L;13.800

Dx/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome frontotemporoparietal dextra (S06.5)+ vulnus laceratum at parietooccipital sinistra (S01.0)

Mechanism of injury in head trauma

Direct trauma by compression or crushing Acceleration-Deceleration Injuries
Brain has inertia. For example, when a person falls backwards onto a hard floor, the back of the persons head hits the floor and stops. The brain, however, is still moving until it strikes the inside of the skull. If the brain gets bruised, there is bleeding, also called a hemorrhage. This bleeding causes further damage to the brain. The skull does not need to strike an object in order for the brain to get injured. There are many situations in motor vehicle crashes where the forces are transmitted through the brain without the skull hitting the dashboard, windshield, steering wheel or window.
Coup/Contrer-Coup Injuries: Related to acceleration-deceleration injuries (e.g injury to
temporal lobe in contralateral temporal trauma)

Subdural Hematoma
A subdural hematoma (SDH) is a form of traumatic brain injury in which blood gathers between the dura and the arachnoid.

Subdural Hematoma

Subdural hematomas
Occur between the dura and the arachnoid mater. Typically, low-pressure venous bleeding of bridging veins (superior cerebral veins) (between the cortex and venous sinuses) dissects the arachnoid away from the dura and layers out along the cerebral convexity Can be acute, subacute or chronic CT Scan shows a crescent shaped clot. It conforms to the shape of the brain and the cranial vault, exhibiting concave inner margins and convex outer margins

a) Acute subdural hematomas most common types of intracranial hematomas. often occur in head trauma from falls and motor vehicle accidents,assults. Associated with compression of the brain and cerebral edema and which increase intracranial pressure Mortality and morbidity are high
b) Subacute subdural hematomas Take a week for symptoms to develop. c) Chronic subdural hematomas develop over weeks or months. occur mostly in old patients esp those taking antiplatelet and anticoagulant drugs and with brain atrophy. common in alcoholics (susceptible to falls) Increased intracranial pressure and cerabral edema are unusual.

Acute Subdural Hematoma

Crescent shaped; Hyperdense, may contain hypodense foci due to serum, CSF or active bleeding

Diagnosis
Radiographic findings
hyperdense crescent-shaped

Diagnostic Imaging
Noncontrast head CT scan (imaging study of choice for acute SDH)
The SDH appears as a hyperdense (white) crescentic mass along the inner table of the skull, most commonly over the cerebral convexity in the parietal region. The second most common area is above the tentorium cerebellum

History
Usually involves moderately severe to severe blunt head trauma Acute deceleration injury from a fall or motor vehicle accident, but rarely associated with skull fracture Generally loss of consciousness Any degree or type of coagulopathy should heighten suspicion of SDH Commonly seen in alcoholics because theyre prone to thrombocytopenia, prolonged bleeding times, and blunt head trauma Patients on anticoagulants can develop SDH with minimal trauma and warrant a lowered threshold for obtaining a head CT scan

Epidemiology
Trauma - Frequency is related directly to the incidence of blunt head trauma -Its the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries Acquire coagulopathies Anticoagulation therapy Congenital bleeding disorders Arteriovenous malformations Aneurysm rupture

Mortality/Age
Mortality
Simple SDH (no parenchymal injury) is associated with a mortality rate of about 20% Complicated SDH (parenchymal injury) is associated with a mortality rate of about 50%

Age
Its associated with age factors related to the risk of blunt head trauma More common in people older than 60 years (bridging veins are more easily damaged/falls are more common) Bilateral SDHs are more common in infants since adhesions existing in the subdural space are absent at birth

Diagnosis
Clinical manifestations
Headache Nausea Vomiting Alteration of consciousness or neurological status Pupillary dilatation

Focal neurological deficit

Intracranial shift or herniation
Note: For people taking anticoagulants e.g aspirin, the possibility of developing intracranial hematomas from minor head injuries is increased.

Treatment
Subdural hematomas Symptoms: persistent headache, fluctuating drowsiness, confusion, memory changes, paralysis on the side of the body opposite the hematoma, and speech or language impairment. Small ones require no treatment because the blood is absorbed on its own. Large ones removed by surgery, (a drain is usually inserted and left in place for several days). monitored closely for recurrences.

Treatment
Surgical evacuation
Indications
Significant mass effect
Thickness of hematoma > 10 mm Midline shift > 5 mm

Decrease in GCS score by 2 or more Loss of pupillary reactivity or pupillary dilatation

Outcomes
Degree of mass effect is more important than Extracerebral mass lesions Associated factor
age, time to evacuation, admission GCS score, hypoxia or hypotention, extent of primary brain injury, duration of coma, mechanism of injury, present of coagulopathy

Thank you

NP 1. Mr Romlan/73 yo// 13060729/Trauma/MZ

CC : decreased of conciousness History : 2 hours prior to admission, when he was walking at Husein area, suddenly he was strucked by motorcycle from behind. he fell down and him head hit the ground. History of unconscious (+), vomiting (-), bleeding from ear (-), nose (+) and mouth (-). he was brought direcly to Emergency Hasan Sadikin Hospital. Primary Survey : A : Clear + C-Spine control B : Shape and movement simmetrycal ; Rh -/- ; RR = 20x/m C : BP : 120/90 mmHg PR : 82 x/m D : GCS E3M5V2 = 10 Pupil round unequal ODS 3/5 mm LR +/+ Motoric : no paresis Secondary Survey : At left parietal : hematome (+), VL size 3x1x1 based on subcutis At Left occipital : vulvus laceratum (+) size 5x1x1 cm based on subcutis

Head CT Scan (Hasan Sadikin ,14-6-2013)

Head CT Scan :

Soft tissue swelling ar left parietooccipital et left frontal Bone discontinuity (-) Sylfian fissure compressed Sulcy and gyri compressed Hyperdense mass crescent shape at right frontotemporoparietal Ventricle and cysterns are compressed Midline shift > 5 mm to the left

Thorax x-ray: within normal limit

Lab :

Hb HMT Leko Trombo

14.4 42 13800 193.000

GDS Na K ur cr

137 138 3.4 30 1.05

WD/

moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital (S01.0) Craniotomy Evacuation

Th/

ICU Ward GCS this morning E3M6V5 = 14

Intra Operative Finding :

WD/ moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital (S01.0)

Th/

Craniotomy Evacuation

DO :

a/r left temporoparietooccipital : - Duramater intact, bluish, tensed - SDH clot 30 cc, lysis 5 cc, from Bridging vein - GCS pre op : E3M5V2 = 10 - Interval op : 10 hours