Subdural hematoma (SDH) has a variable disease course, depending on size of hematoma, age of the patient, presenting neurologic signs/symptoms, presence of underlying coagulopathy or neoplasm, and associated injuries.
One week of prophylactic antiepileptic therapy (e.g., phenytoin, levetiracetam) should be considered in all cases of acute and acute-on-chronic SDH, according to the Brain Trauma Foundation guidelines.
Aggressive reversal of coagulopathy should be accomplished in most patients with SDH who are taking anticoagulants.
Surgical therapy is usually indicated for acute or chronic SDHs that are expansile or causing neurologic deficit. Observation may be employed for small, stable SDHs that are not causing neurologic compromise.
Control of elevated intracranial pressure using head-of-bed elevation, analgesics, intubation with anesthetics and sedation, hyperosmolar treatment, barbiturates, or decompressive hemicraniectomy may be required.
Treatment complications include early or delayed reaccumulation of SDH, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the hematoma, strokes, persistent neurologic deficit, coma, and death.
SDH is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the hematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of SDH can be inferred by neurologic decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (computed tomography or magnetic resonance imaging).
History and exam
Key diagnostic 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
- localized weakness
- sensory changes
- cognition changes
- speech or vision changes
- recent trauma
- coagulopathy and anticoagulant use
- advanced age (>65 years)
1st investigations to order
- noncontrast CT scan
Investigations to consider
- MRI scan
- plain skull x-ray
with ventriculoperitoneal shunt
- Epidural hematoma
- Intracerebral hematoma
- Diffuse axonal injury
- Head injury: assessment and early management
- ACR appropriateness criteria: head trauma
Glasgow Coma Scale
Canadian CT Head RuleMore Calculators
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