subdural hematoma
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Introduction
collection of blood between dura mater & arachnoid membranes of the central nervous system.
acute & subacute subdural hematomas (complicated subdural hematomas) are associated with brain, edema & poor prognosis
bleeding may be arterial or venous
Etiology
- trauma
- acute subdural hematoma
- cortical & parenchymal lacerations
- no lucid interval
- brain injury severe
- size of hematoma is insignificant
- tear in large bridging vein or dural sinus
- often lucid interval
- brain injury less severe
- posterior fossa subdural hematoma
- falls in the elderly or head trauma in the elderly[5]
- may occur in the absence of significant trauma, especially in anticoagulated elderly patients[3] or in elderly with significant cerebral atrophy[7]
- cortical & parenchymal lacerations
- acute subdural hematoma
- coagulopathy
- cancer chemotherapy
- anticoagulant therapy
- hematologic disease
- hypovitaminosis
- arteriovenous malformation or rupture of aneurysm into the subdural space
- lumbar puncture
- intracranial procedures
- neoplasms
- primary
- metastatic to subdural space
- alcoholism
- hypertension
- hemodialysis
- infusion of osmotic diuretics
- infection
Epidemiology
- more common in elderly
- subdural hematomas may occur in the absence of trauma, especially in the elderly taking anticoagulant
Pathology
- age-related brain atrophy predisposes elderly to subdural hematoma likely due to traction on bridging dural veins
- chronic subdural hematoma is an inflammatory process, thus the rational for use of glucocorticoids in management
Clinical manifestations
- acute subdural hematoma:
- symptoms occur within 24 hours of injury
- pupillary asymmetry or fixation warrant neurosurgical consultation
- subacute & chronic subdural hematoma
- subacute: symptoms occur within 3-21 days of injury
- chronic:
- symptoms occur after 3 weeks of injury
- altered mental status, somnolence
- focal neurologic signs, bilateral in 15-20%
- calcified chronic subdural hematomas
- generally bilateral
- may be asymptomatic for years
- incidental finding
- seizures
- mental retardation
- dull headaches
- seizures
- altered mental status or somnolence
- personality changes
- focal neurologic deficits
- dysphagia
- hemiparesis
- hemisensory dysfunction
- ocular signs/symptoms
- spinal subdural hematoma
- may occur secondary to lumbar puncture
- sphincter dysfunction
- paraplegia
- back pain
Diagnostic procedures
- subdural tap:
- infantile chronic subdural
- coagulated hematoma may give dry tap
- B-mode ultrasonography: infantile chronic subdural
- cerebral angiography
- electroencephalogram (EEG) non-specific[2]
Radiology
- computed tomography (CT) without contrast (first line)*
- magnetic resonance imaging (MRI)
- radiographs of skull
- skull fracture
- shift of midline calcifications
- calcified subdural membrane
- radioisotope brain scan
* subtle subdural hematoma on CT neuroimaging[5]
Complications
Differential diagnosis
- epidural hematoma: temporal region, may be lucid interval
Management
- neurosurgical drainage
- symptomatic
- > 1 cm thick, midline shift of > 5 mm, or Glascow coma scale < 9
- mortality 30% if surgery within 4 hours of injury
- dexamethasone
- chronic subdural
- recollection of fluid after surgical drainage
- 2-4 mg BID-QID for 7-14 days
- spinal subdural hematoma
- prognosis
- acute subdural
- mortality 50-90%
- 60% in elderly
- 90% in anticoagulated patients
- mortality 50-90%
- chronic subdural
- mortality < 10%
- 75% complete recovery
- if paroxysmal atrial fibrillation with high CHADs score, restart apixban if CT shows reduction in size of hematoma[2]
- acute subdural
* depsite lack of clear guidance by in literature, whether & when to resume antithrombotic therapy is a clinical decision[2]
More general terms
More specific terms
Additional terms
References
- ↑ 1.0 1.1 1.2 Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1083-85
- ↑ 2.0 2.1 2.2 2.3 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 3.0 3.1 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Panczykowski DM, Okonkwo DO. Premorbid oral antithrombotic therapy and risk for reaccumulation, reoperation, and mortality in acute subdural hematomas. J Neurosurg. 2011 Jan;114(1):47-52 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20722610
- ↑ 5.0 5.1 Abraham MK, Cimino-Fiallos N Falls in the Elderly: Causes, Injuries, and Prevention. Medscape. Nov 23 2022 https://reference.medscape.com/slideshow/falls-in-the-elderly-6012395
- ↑ Mehta V, Harward SC, Sankey EW et al. Evidence based diagnosis and management of chronic subdural hematoma: a review of the literature. J Clin Neurosci. 2018;50:7-15. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29428263
- ↑ 7.0 7.1 NEJM Knowledge+