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.
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
- diminished eye response
- diminished verbal response
- diminished motor response
Other diagnostic factors
- loss of consciousness/decreased alertness
- loss of bowel and bladder continence
- localised weakness
- sensory changes
- cognition changes
- speech or vision changes
- recent trauma
- coagulopathy and anticoagulant use
- advanced age (>65 years)
1st investigations to order
- non-contrast CT scan
Investigations to consider
- MRI scan
- plain skull x-ray
with ventriculoperitoneal shunt
Andrew W. Grande, MD
Assistant Professor of Neurosurgery
University of Minnesota
AWG declares that he has no competing interests.
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.
Nathan J. Ranalli, MD
Department of Neurosurgery
University of Pennsylvania School of Medicine
NJR declares that he has no competing interests.
Marek Ma, MD
Department of Emergency Medicine Administrative Offices
University of Pennsylvania
MM declares that he has no competing interests.
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