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subdural hematoma

- 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: 1) 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] - falls in adults presenting with severe neurological impairment - may occur in the absence of significant trauma, especially in anticoagulated elderly patients [3] or in elderly with significant cerebral atrophy [7] 2) coagulopathy a) cancer chemotherapy b) anticoagulant therapy b) hematologic disease - hemophilia c) hypovitaminosis - vitamin K - vitamin C 3) arteriovenous malformation or rupture of aneurysm into the subdural space 4) lumbar puncture 5) intracranial procedures 6) neoplasms a) primary b) metastatic to subdural space 7) alcoholism 8) hypertension 9) hemodialysis 10) infusion of osmotic diuretics 11) infection Epidemiology: - more common in elderly - subdural hematomas may occur in the absence of trauma, especially in the elderly taking anticoagulant - subdural hematoma is the most common traumatic intracranial bleed after a fall in adults, especially those presenting with severe neurological impairment 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: 1) acute subdural hematoma: - symptoms occur within 24 hours of injury - pupillary asymmetry or fixation warrant neurosurgical consultation 2) subacute & chronic subdural hematoma a) subacute: symptoms occur within 3-21 days of injury b) chronic: a) symptoms occur after 3 weeks of injury b) altered mental status, somnolence c) focal neurologic signs, bilateral in 15-20% d) calcified chronic subdural hematomas - generally bilateral - may be asymptomatic for years - incidental finding - seizures - mental retardation c) dull headaches d) seizures e) altered mental status or somnolence f) personality changes g) focal neurologic deficits - dysphagia - hemiparesis - hemisensory dysfunction h) ocular signs/symptoms - papilledema - retinal hemorrhage - photophobia i) neck pain* (case report [3] j) ataxia* (case report) [3] 3) spinal subdural hematoma a) may occur secondary to lumbar puncture b) sphincter dysfunction c) paraplegia d) back pain * the pathophiology of the neck pain & ataxia not explained [3] * Open evidence suggests the pathophysiology causing ataxia & neck pain involves mechanical compression of the cerebellum & brainstem, & irritation of the meninges & spinal nerve roots (ciring posterior fossa & spinal hematomas) Special laboratory: 1) subdural tap: a) infantile chronic subdural b) coagulated hematoma may give dry tap 2) B-mode ultrasonography: infantile chronic subdural 3) cerebral angiography 4) electroencephalogram (EEG) non-specific [2] Radiology: 1) computed tomography (CT) without contrast (first line)* - crescent-shaped hyperintensity (acute), hypodensity (chronic) [1] - MKSAP20 presents case with high-attenuation claimed to be crescentic, but imaginary at best [3] - no need for third CT if repeat CT shows reduction in size [1] 2) magnetic resonance imaging (MRI) 3) radiographs of skull a) skull fracture b) shift of midline calcifications - pineal - falx cerebri c) calcified subdural membrane 4) radioisotope brain scan * subtle subdural hematoma on CT neuroimaging [5] Differential diagnosis: - epidural hematoma: temporal region, may be lucid interval Complications: - brain death Management: 1) neurosurgical drainage a) symptomatic b) > 1 cm thick, midline shift of > 5 mm, or Glascow coma scale < 9 c) mortality 30% if surgery within 4 hours of injury d) low-dose aspirin (100 mg) may be continued during burr hole drainage [9] 2) dexamethasone a) chronic subdural b) recollection of fluid after surgical drainage c) 2-4 mg BID-QID for 7-14 days 3) spinal subdural hematoma - laminectomy 4) reverse anticoagulation in patients with intracranial bleeding - four-factor prothrombin complex concentrate - andexanet alfa for reversal of apixaban anticoagulation [3] 5) prognosis a) acute subdural - mortality 50-90% - 60% in elderly - 90% in anticoagulated patients b) 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] * depsite lack of clear guidance by in literature, whether & when to resume antithrombotic therapy is a clinical decision [2]

Related

epidural hematoma post concussion syndrome

Specific

complex subdural hygroma

General

intracranial hematoma cerebrovascular hemorrhage

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1083-85
  2. 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. 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 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  4. 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: 20722610
  5. 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
  6. 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: 29428263
  7. NEJM Knowledge+
  8. Nouri A, Gondar R, Schaller K, et al. Chronic subdural hematoma (cSDH): a review of the current state of the art. Brain Spine. 2021;1:100300. PMID: 3624739
  9. Kamenova M et al. Aspirin continuation or discontinuation in surgically treated chronic subdural hematoma. JAMA Neurol 2025; 82:551 PMID: 40287938 PMCID: PMC12035736 (available on 2026-04-27) https://jamanetwork.com/journals/jamaneurology/fullarticle/2832855

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