Subdural haematoma

Last reviewed: March 2019

Last updated: August 2018

Summary

Variable disease course, depending on size of haematoma, age of the patient, presenting neurological signs/symptoms, presence of underlying coagulopathy or neoplasm, and associated injuries.

One week of antiepileptic therapy (e.g., phenytoin, levetiracetam) should be considered in all cases of acute and acute-on-chronic subdural haematoma, according to the Brain Trauma Foundation guidelines.

Aggressive reversal of coagulopathy should be accomplished in most patients with a subdural haematoma who are taking anticoagulants.

Surgical therapy is usually indicated for acute or chronic subdural haematomas that are expansile or causing neurological deficit. Observation may be employed for small, stable subdural haematomas that are not causing neurological compromise.

Control of raised intracranial pressure using head-of-bed elevation, analgesics, intubation with anaesthetics and sedation, hyperosmolar treatment, external ventricular drainage, barbiturates, or decompression hemicraniectomy may be required.

Treatment complications include early or delayed re-accumulation of subdural haematoma, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the haematoma, strokes, persistent neurological deficit, coma, and death.

Definition

A subdural haematoma is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the haematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of subdural haematoma can be inferred by neurological decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (computed tomography or magnetic resonance imaging).

History and exam

Key diagnostic factors

presence of risk factors
evidence of trauma
headache
nausea/vomiting
diminished eye response
diminished verbal response
diminished motor response
confusion

Full details

Other diagnostic factors

loss of consciousness/decreased alertness
seizure
loss of bowel and bladder continence
localised weakness
sensory changes
cognition changes
speech or vision changes
otorrhoea
rhinorrhoea

Full details

Risk factors

recent trauma
coagulopathy and anticoagulant use
advanced age (>65 years)

Full details

Diagnostic investigations

1st investigations to order

non-contrast CT scan

Full details

Investigations to consider

MRI scan
plain skull x-ray

Full details

Treatment algorithm

ACUTE

acute haematoma

with ventriculoperitoneal shunt

ONGOING

chronic haematoma

Contributors

Authors VIEW ALL 

Andrew W. Grande, MD

Assistant Professor of Neurosurgery

University of Minnesota

Minneapolis

Disclosures

AWG declares that he has no competing interests.

Acknowledgements

Dr Andrew W. Grande would like to gratefully acknowledge Dr Stephen J. Haines, Dr Praveen R. Baimeedi, Dr Jason S. Hauptma, and Dr Neil A. Martin, previous contributors to this topic. SJH, PRB, JSH, and NAM declare that they have no competing interests.

Peer reviewers VIEW ALL 

Nathan J. Ranalli, MD

Resident

Department of Neurosurgery

University of Pennsylvania School of Medicine

Philadelphia

Disclosures

NJR declares that he has no competing interests.

Marek Ma, MD

Instructor

Emergency Medicine

Department of Emergency Medicine Administrative Offices

University of Pennsylvania

Philadelphia

Disclosures

MM declares that he has no competing interests.

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Subdural haematoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute haematoma

with ventriculoperitoneal shunt

chronic haematoma

Contributors

Authors VIEW ALL 

Andrew W. Grande, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Nathan J. Ranalli, MD

Disclosures

Marek Ma, MD

Disclosures

Differentials

Guidelines

Calculators

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