Subdural hematoma

Last reviewed: March 2019

Last updated: August 2018

Summary

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

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

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

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

Treatment complications include early or delayed reaccumulation of subdural hematoma, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the hematoma, strokes, persistent neurologic deficit, coma, and death.

Definition

A subdural hematoma 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 subdural hematoma 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
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
localized weakness
sensory changes
cognition changes
speech or vision changes
otorrhea
rhinorrhea

Full details

Risk factors

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

Full details

Diagnostic investigations

1st investigations to order

noncontrast CT scan

Full details

Investigations to consider

MRI scan
plain skull x-ray

Full details

Treatment algorithm

ACUTE

acute hematoma

with ventriculoperitoneal shunt

ONGOING

chronic hematoma

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 hematoma

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 hematoma

with ventriculoperitoneal shunt

chronic hematoma

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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