Acute Subdural Hematoma

Manish KC, MBBS (1), Junaid Siddiqui, MD, MRCP(2)
1 - KIST Medical College & Teaching Hospital, Nepal.
2 - Department of Neurology, University of Missouri, Columbia, USA


Introduction

  • Extravasation of blood into the subdural space between the dura and arachnoid membranes
  • Most common neurosurgical emergency associated with high morbidity and mortality
  • A potentially life-threatening condition requiring urgent surgical evacuation for good clinical outcomes

Epidemiology

  • mostly traumatic but can be spontaneous
  • 50-90% death rate in acute traumatic SDH
  • Incidence of traumatic SDH: 11-49%
  • After surgical evacuation, recurrent rates as high as 20% in some cases
  • Most commonly seen in MVAs in the younger population and from falls in the older age group
  • May have a lucid interval in 12-38% of patients
  • 35-80% present with GCS ≤8 with a mortality of 55-70%
  • Death in patients with GCS 3-15: 30-60%

Etiology

  • Rupture of the bridging veins
  • Mostly traumatic but can be spontaneous
  • Spontaneous causes of acute SDH: anticoagulants/antiplatelet use, intracranial aneurysmal rupture
  • Less common causes: AVMs rupture, cocaine abuse, vascular meningiomas, dural metastases, etc
 

Figure 1: Acute Subdural Hematoma on CT Brain

notion image
Case courtesy of Dr Andrew Ho, Radiopaedia.org, rID: 23274

Types

  • Parafalcine and tentorial
    • Seen in younger patients with mild traumatic brain injury
    • Managed nonoperatively
  • Posterior fossa
    • Rare
    • Poor outcome
    • 50% death rate
    • Coagulopathy present
    • Associated with low GCS score and occipital fracture
  • Non-traumatic
    • Seen in ruptured intracranial aneurysms, cancers, anticoagulants use, AIDS, bleeding disorders

Pathophysiology

  • Cerebral blood flow changes
    • Reduces significantly instantly after injury due to a decrease in CPP and an increase in ICP
    • Cerebral vasoconstriction and defect in autoregulation after brain trauma also contribute to a decrease in CBF
    • Hyperemia/hyperperfusion occurs followed by reperfusion injury by oxygen-derived free radicals that are associated with poor clinical outcome
  • Coagulopathy
    • Occur following traumatic brain injury
    • Trigger coagulation pathway increases the likelihood of bleeding
    • Affects hemostasis, intracerebral hematoma formation, and expansion that lead to poor clinical outcomes
  • Delayed deterioration
    • Also known as talk and deteriorate
    • Seen in the elderly
    • Seen within 6 hours after trauma
    • Atrophied brains in the elderly allow more intracranial space to accumulate blood and cerebral edema before clinical deterioration occurs
    • Early identification and evacuation of hematoma are important to avoid this phenomenon

Clinical Features

  • Headache
  • Altered mental status
  • Nausea/vomiting
  • Lethargy
  • Motor weakness
  • Seizures
  • Stupor
  • Coma

Differential Diagnosis

  • Epidural hematoma
  • Subarachnoid hemorrhage
  • Meningitis
  • Encephalitis
  • Intracerebral hemorrhage

Diagnosis

  • Non-contrast CT scan of Head: easily available, Crescent shaped mass, sensitivity nearly 100%
  • MRI is superior to CT in identifying small SDH, tentorial, and interhemispheric SDH
  • Additional findings like midline shift, brain herniation, associated brain injuries can be seen in brain imaging
  • Digital subtraction angiography in non-traumatic acute SDH for suspected rupture of a cerebral aneurysm
 

Treatment

  • Emergent resuscitation
  • Neurosurgical consultation
  • Maintenance of airway, breathing, and circulation
  • Maintain Pao2> 60mm Hg and MAP> 65mm Hg
  • Intubate patient, if unable to maintain the airway
  • Rapid sequence intubation to facilitate endotracheal intubation
  • Adequate intravenous access
  • Reversal of anticoagulation to avoid hematoma expansion
  • Intracranial pressure monitoring and treatment
    • Elevate head of bed to 300
  • Intracranial pressure Treatment
    • ICP treatment only recommended if the patient is a surgical candidate and on the way to surgical intervention
    • Brief Hyperventilation to maintain PaCO2 of 32-36 mm Hg (max 4 hours)
    • Osmolar therapy with Mannitol 1 to 1.5g/kg and/or 30 to 120ml of 23.4% Hypertonic saline (on the way to surgical suite)
  • Seizure prophylaxis: Phenytoin/fosphenytoin or Levetiracetam
  • Blood pressure and cerebral perfusion pressure management
    • Maintain CPP above 60 mm Hg in adults and 40-65mm Hg in children
  • Analgesia
    • Fentanyl- 25 to 200 mcg/hr
    • Remi-fentanyl- 0.5 to 2 mcg/kg/min
  • Sedation
    • Propofol- 5mcg/kg/min followed by increase in 5-10mcg/kg/min until adequate sedation is achieved
  • Temperature control
    • Maintain normothermia by acetaminophen
  • Glucose control
    • Maintain blood glucose level 120-180 mg/dl
    • Avoid hyperglycemia using insulin sliding scales
  • Stress ulcer prophylaxis
    • PPIs preferred over H2 blockers, sucralfate

Indications for emergent surgery

  • A rapid decline in neurological statusMydriasis: unilateral or bilateralExtensor postureMidline shift in CT Head > 5mmHematoma size in CT Head > 10mm
  • Neurosurgical evacuation under general anesthesia

Complications

  • Brain herniation
  • Coma
  • Death

Prognosis

  • Prognosis depends upon age, neurological condition, radiological appearance, the timing of neurosurgery, associated brain injuries, extracranial injuries, and postoperative care
  • 25-50% of cases are comatose after the trauma
  • 12-38% of cases undergo gradual neurological deterioration followed by coma a few hours after the trauma
  • Overall bad prognosis in serious trauma to the brain parenchyma, associated brain edema and/or herniation
 

Bibliography

  • Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC. Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med. 1981;304(25):1511–8.
  • Matsuyama T, Shimomura T, Okumura Y, Sakaki T (1997) Rapid resolution of symptomatic acute subdural hematoma: case report. Surg Neurol 48:193–196
  • Tallon JM, Ackroyd-Stolarz S, Karim SA, Clarke DB. The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study. Can J Surg. 2008;51:339-345.
  • Okuno S, Touho H, Ohnishi H, et al. Falx meningioma presenting as acute subdural hematoma: case report. Surg Neurol 1999;52:180–4.
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