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Subdural Hematoma

Hematomas Subdural

Subdural hematoma is defined as a collection of blood outside the brain below the dura mater.


Presentation

Presentations seen is dependent on the level of bleeding but general include siezures, apathy, weakness, lethargy, nausea, dizziness, behaviorual changes, confusion and severe headache

Chronic subdural hematoma may have presentation similar to what is seen with Parkinson disease. An acute presentation is equally possible as seen in patients who show seizure as a symptom.

Confusion and headache appears to be the most common presenting features as it is seen in as much as 90% to 56% of cases.

Epilepsy
  • In case of refractory treatment of epilepsy, dislocation of pacemaker electrodes is a, most certainly, rare but possible differential diagnosis.[ncbi.nlm.nih.gov]
  • As many as 10 percent of patients had a history of alcoholism or epilepsy, the Welsh team reported. Obesity can be a contributing factor by increasing estrogen levels in the body, Dr. Samadani said.[well.blogs.nytimes.com]
  • […] subdural hematoma include the following: Mild or severe head trauma Acute subdural hematoma following surgey Spontaneous Risk factors for chronic subdural hematoma include the following: Diabetes Thrombocytopenia Cardiovascular disorder Arachnoid cyst Epilepsy[symptoma.com]
  • Preparation for Surgery Phenytoin is administered to decrease the risk of developing early posttraumatic seizures (within the first 7 days after the injury). [31] Patients have an estimated risk of greater than 20% for developing posttraumatic epilepsy[emedicine.medscape.com]
  • Complications of surgical evacuation such as recurrent hematoma, postoperative epilepsy, brain injury and/or iatrogenic intracerebral bleeding due to hematoma evacuation, drainage insertion or irrigation, and ways to avoid them are also discussed.[intechopen.com]
Fatigue
  • Classic symptoms of a chronic subdural hematoma include recurring headaches , personality changes, fatigue and dementia. Dementia in a subdural hematoma can be sometimes mistakenly confused with incipient Alzheimer's disease .[health-tutor.com]
  • Vomiting, numbness, and fatigue are also key manifestations. 7.[thrombocyte.com]
  • Clinical presentation varies from general and mild symptoms (e.g. headache, fatigue) to severe symptoms (e.g. hemiparesis, coma).[intechopen.com]
Nausea
  • Four hours postoperatively, the patient complained of headache and nausea. Enhanced cranial computed tomography showed cerebral SDH.[ncbi.nlm.nih.gov]
  • Although headache and nausea are common side effects of vardenafil, hemorrhagic diseases should also be considered when symptoms are severe or prolonged.[ncbi.nlm.nih.gov]
  • The patient is a 56-year-old woman with a gastrointestinal stromal tumor who presented with headache, nausea, and vomiting lasting 2 weeks. An MRI to rule out brain metastasis found a large right-hemispheric subdural hematoma without metastases.[ncbi.nlm.nih.gov]
  • Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%.[ncbi.nlm.nih.gov]
  • In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain.[ncbi.nlm.nih.gov]
Vomiting
  • A 28-year-old healthy man was admitted to our hospital because of right-sided headache, vomiting, and lower back pain after the administration of vardenafil.[ncbi.nlm.nih.gov]
  • The patient is a 56-year-old woman with a gastrointestinal stromal tumor who presented with headache, nausea, and vomiting lasting 2 weeks. An MRI to rule out brain metastasis found a large right-hemispheric subdural hematoma without metastases.[ncbi.nlm.nih.gov]
  • Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%.[ncbi.nlm.nih.gov]
  • Symptoms include: Headache Weakness or numbness in arms, legs, or face Poor balance or coordination Change in behavior, emotions, or memory Drowsiness, lethargy, or coma Changes in vision Trouble speaking, swallowing, or communicating Nausea/vomiting[sharecare.com]
  • Depending on the size of the hematoma and where it presses on the brain, any of the following symptoms may occur: Confused or slurred speech Problems with balance or walking Headache Lack of energy or confusion Seizures or loss of consciousness Nausea and vomiting[medlineplus.gov]
Hypertension
  • Cerebral atrium diverticula are focal enlargements of the ventricular system that may develop in the presence of persistent intracranial hypertension, but they are rarely described in cases of acute intracranial hypertension.[ncbi.nlm.nih.gov]
  • This patient had no history of hypertension. We evaluated the relevant literature to analyze the causes of cerebral hemorrhage in similar patients.[ncbi.nlm.nih.gov]
  • We hypothesize that augmentation of venous blood egression through the emissary veins during surgery may have led to venous hypertension and subsequently the development of the chronic subdural hematoma.[ncbi.nlm.nih.gov]
  • Detailed chart review was performed, and cases are described in relation to anatomy and proposed pathophysiology of venous hypertension and arterial vasospasm.[ncbi.nlm.nih.gov]
  • Further prospective randomized controlled study is warranted in stable patients without evident intracranial hypertension and impending cerebral herniation.[ncbi.nlm.nih.gov]
Anisocoria
  • The period from losing consciousness to brain herniation presenting as anisocoria was very short-only 30 minutes in our patient.[ncbi.nlm.nih.gov]
  • There are often signs of brainstem compression: miosis, mydriasis, nystagmus, anisocoria, flaccid or hypertonic limbs, and eye deviation.[ahcmedia.com]
Pupillary Abnormality
  • Other poor prognostic indicators for acute SDH have been reported to include the initial and postresuscitation Glasgow coma scale (GCS) score, the GCS motor score on admission, pupillary abnormalities, alcohol use, injury by motorcycle, ischemic damage[emedicine.medscape.com]
  • Most patients (65-80%) present with a severely depressed conscious state, and pupillary abnormalities are seen in 40% (range 30-50%) of cases 5 .[radiopaedia.org]
Diplopia
  • The symptoms gradually worsened, and on the day of presentation to an outside hospital emergency department, the patient complained of nausea, vomiting, and diplopia.[ajnr.org]
Hemianopsia
  • Common neurological signs include aphasia, cranial nerve palsies, hemiparesis, hemisensory deficits, gait disturbances, and hemianopsia. 19,25,28,62 The majority of subdural hygromas are asymptomatic.[ahcmedia.com]
Urinary Incontinence
  • In elderly patients with CSDH, symptoms of cognitive change (memory disturbance, urinary incontinence, and decreased activity) and disturbance of consciousness at admission were more frequent compared to younger patients with CSDH.[ncbi.nlm.nih.gov]
  • A 55-year-old man was admitted to our hospital complaining of headache, seizure, and urinary incontinence. He had a history of alcoholism and several hospitalizations for mild head trauma.[ncbi.nlm.nih.gov]
Headache
  • Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift.[ncbi.nlm.nih.gov]
  • The most common complication of spinal anesthesia is the postdural puncture headache. When severe and persistent headache after spinal anesthesia occur, differential diagnosis can be explored.[ncbi.nlm.nih.gov]
  • We review the headaches and other clinical features associated with chronic SDH. Twelve cases of roller coaster headaches due to SDH associated with riding roller coasters have been reported.[ncbi.nlm.nih.gov]
  • A 28-year-old healthy man was admitted to our hospital because of right-sided headache, vomiting, and lower back pain after the administration of vardenafil.[ncbi.nlm.nih.gov]
  • Ten of 11 patients had signs consistent with postdural puncture headache before the diagnosis of SDH.[ncbi.nlm.nih.gov]
Seizure
  • The latter might then cause unintended skeletal muscle stimulation that might be misinterpreted in seizure-prone patients.[ncbi.nlm.nih.gov]
  • He had a generalized seizure on arrival to hospital and no history of trauma. A computed tomography demonstrated an acute left-sided SDH.[ncbi.nlm.nih.gov]
  • Chronic SDH may present with headaches, light-headedness, cognitive impairment, and seizures. 1 The risk of posttraumatic epileptic seizures (PTS) is higher in acute SDH.[jetem.org]
  • Seizures often occur at the time the hematoma forms, or up to months or years after treatment. But medicines can help control the seizures.[medlineplus.gov]
Confusion
  • The high recurrent rate of chronic subdural hematoma (CSDH) has consistently confused the neurosurgeons, and the role of atorvastatin in the management of CSDH has remained unclear over past decade, and atorvastatin seems to be a safe and cost-effective[ncbi.nlm.nih.gov]
  • On postoperative day 2, he became confused; and head CT demonstrated intracranial SAH with blood products along the superior cerebellum and bilateral posterior Sylvian fissures.[ncbi.nlm.nih.gov]
  • Confusion and headache appears to be the most common presenting features as it is seen in as much as 90% to 56% of cases.[symptoma.com]
  • […] two weeks after bleeding begins Symptoms of subdural hematoma can include headache, confusion, change in behavior, dizziness, nausea and vomiting, lethargy or excessive drowsiness, weakness, apathy, and seizures.[pacificneuroscienceinstitute.org]
  • Ipsilateral symptoms were observed in 12 instances, confusion or obnubilation in 40, papillary edema in 16, motor pareses in 45 and epileptic attacks in 20.[jamanetwork.com]
Stroke
  • Google Scholar strokeaha Stroke Stroke Stroke 0039-2499 1524-4628 Lippincott Williams & Wilkins Response Gebel James M., MD and Sila Cathy A., MD 01 1999 We wish to thank Dr Kasner for his most eloquent and convincing mathematical explanation of our serendipitous[stroke.ahajournals.org]
  • Página 311 - The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. ‎[books.google.es]
  • The most common indication for antithrombotic treatment before onset of CSDH was atrial fibrillation (29.6%), followed by prosthetic heart valve (16.6%), recent myocardial infarction (14.1%), prior stroke or transient ischemic attack (11.6%), and finally[ncbi.nlm.nih.gov]
  • Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎[books.google.es]
  • The Neuro-ICU cares for patients with all types of neurosurgical and neurological injuries, including stroke, brain hemorrhage, trauma and tumors.[neurosurgery.ucla.edu]
Lethargy
  • Symptoms include: Headache Weakness or numbness in arms, legs, or face Poor balance or coordination Change in behavior, emotions, or memory Drowsiness, lethargy, or coma Changes in vision Trouble speaking, swallowing, or communicating Nausea/vomiting[sharecare.com]
  • […] subdural hematoma include the following: A history of recent head injury Loss of consciousness or fluctuating levels of consciousness Irritability Seizures Pain Numbness Headache (either constant or fluctuating) Dizziness Disorientation Amnesia Weakness or lethargy[neurolaw.com]
  • Presentations seen is dependent on the level of bleeding but general include siezures, apathy, weakness, lethargy, nausea, dizziness, behaviorual changes, confusion and severe headache.[symptoma.com]
  • […] and/or high blood pressure Weakened blood vessels in the brain Maternal pelvic inflammation Symptoms of Subdural Hematoma in Infants Difficulties with feedings Shrill, high-pitched crying Bulging from the infant’s soft spot on top of the head Extreme lethargy[birthinjuryguide.org]
  • Other symptoms include lethargy, memory impairment, confusion, weakness, nausea, vomiting, impaired vision and seizures. Patients with large hematomas may develop varying degrees of paralysis and coma.[neurosurgery.ucla.edu]

Workup

Following any form of head trauma, medical assessment including complete neurological examination should be conducted on the individual [8]. Most of the time, a CT scan or MRI scan will usually show significant subdural hematomas.

Subdural hematomas are seen mostly around the sides and tops of the parietal and frontal lobes. They are also seen in the posterior cranial fossa as well as near the falx cereberi and tentorium cerebeli. Subdural hematomas can expand along the skull unlike epidural hematomas.

Following a CT scan, subdural hematomas appear crescent-shaped with a concave surface away from the skull. However, they can have a convex appearance especially in the early stage of bleeding.

Treatment

The treatment of subdural hematoma is dependent on both its size and growth rate [9]. Small subdural hematomas can be managed by a wait and monitor approach until the body heals itself. Other forms of SDH can be managed by the insertion of catheter via a hole drilled through the skull to help suck out the hematoma. Larger hematomas or symptomatic hematomas often require a craniotomy.

Prognosis

Mortality for cases of subdural hematoma has been put at 36 to 79% [5]. Most of the time, survivors are not able to regain previous levels of functionality especially following acute subdural hematoma that is serious enough to warrant surgical drainage. Positive outcomes in cases of subdural hematoma is seen 14 to 40% of the time.

Studies show that outcome is often favourable in younger patients [6].

Etiology

The main causes of acute subdural hematoma may include any of the following [2]:

The main causes of chronic subdural hematoma include the following:

Risk factors for chronic subdural hematoma include the following:

Epidemiology

Acute subdural hematomas have been noted to occur in 5 to 25% of patients that have severe head injuries with annual cases reported to be 1 to 5.3 cases per 100,000 population [3]. Some of the more recent studies show a higher incidence but this may be as a result of better imaging techniques.

There is sexual preponderance as SDH is seen more in men than in women. Male to female ratio is approximately 3:1. Men equally have a higher incidence of chronic subdural hematoma. The male to female ratio for chronic subdural hematoma is 2:1.

The incidence of chronic subdural hematoma is believed to be at its peak within the fifth to seventh decades of life.

Sex distribution
Age distribution

Pathophysiology

An acute subdural hematoma is a condition arising from a high-speed impact to the skull. This can lead to tearing of intracranial blood vessels [4].

Most of the time, the torn blood vessel is a bridging vein which connects the cortical surface of the brain to a dural sinus. In elderly individuals, the dural sinus may already be stretched due to brain atrophy.

Alternatively, a direct injury or laceration can damage a cortical vessel which may be a vein or artery. Acute subdural hematoma as a result of a ruptured cortical artery may be associated with only a minor head injury possibly without any associated cerebral contusion. Arterial injury may result in rapid neurological decline. In some instances, the ruptured cortical arteries were found located around the sylvian fissure. Generally, low-pressure venous bleeding from bridging veins occurs along the convexity. 

The head trauma may equally also cause associated brain hematomas or contusions as well as subarachnoid hemorrhage or diffusing axonal injury. Secondary brain injuries can include secondary haemorrhage, brain herniation, infarction or edema.

Chronic subdural hematomas develop over a time of days to weeks, often after minor head injury. They may not be discovered until they present clinically after a while.

Prevention

The best way to prevent SDH is to prevent head trauma by using adequate protective gear when engaging in risky activities [10]. As soon as the head suffers any form of impact, the individual should undergo medical evaluation. All underlying ailments must also be adequately taken care of.

Summary

A subdural hematoma (SDH) refers to the collection of blood outside the brain below the dura mater [1]. This condition is generally occurs due to severe head injuries and causes increased bleeding and pressure on the brain. This makes it a life-threatening condition. Subdural hematomas often require surgical drainage but in many cases, they resolve and stop without any external interventions.

Patient Information

Subdural hematoma refers to a situation where a vessle get ruptured between the brain and the dura matter. The dura matter refers to one of the three membrane layers that cover your brain. The leaking blood forms a kind of clot which compresses the tissues of the brain. If the clot (hematoma) continues to enlarge, a progressive decline in consciousness often follows and this often leads to death when untreated. Treatment is mostly via surgery.

References

Article

  1. Kotwica Z, Brzezinski J. Acute subdural haematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien). 1993;121(3-4):95-9.
  2. Morinaga K, Matsumoto Y, Hayashi S, Omiya N, Mikami J, Sato H, et al. [Subacute subdural hematoma: findings in CT, MRI and operations and review of onset mechanism]. No Shinkei Geka. Mar 1995;23(3):213-6.
  3. Matsuyama T, Shimomura T, Okumura Y, Sakaki T. Rapid resolution of symptomatic acute subdural hematoma: case report. Surg Neurol. Aug 1997;48(2):193-6.
  4. Gennarelli TA, Thibault LE. Biomechanics of acute subdural hematoma. J Trauma. Aug 1982;22(8):680-6.
  5. Hlatky R, Valadka AB, Goodman JC, Robertson CS. Evolution of brain tissue injury after evacuation of acute traumatic subdural hematomas. Neurosurgery. Jul 2007;61(1 suppl):249-254. 
  6. Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988; 90:111.
  7. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58:S16.
  8. Hatashita S, Koga N, Hosaka Y, Takagi S. Acute subdural hematoma: severity of injury, surgical intervention, and mortality. Neurol Med Chir (Tokyo) 1993; 33:13.
  9. Zumkeller M, Behrmann R, Heissler HE, Dietz H. Computed tomographic criteria and survival rate for patients with acute subdural hematoma. Neurosurgery 1996; 39:708.
  10. Koç RK, Akdemir H, Oktem IS, et al. Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 1997; 20:239.

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Last updated: 2018-06-22 06:43