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Subdural haemorrhage

Specialties > Child health

Background knowledge 🧠

Definition

  • A subdural haemorrhage (SDH) is a collection of blood between the dura mater and the arachnoid mater of the brain.
  • Results from tearing of bridging veins between cortical surface and dural sinuses.
  • Can be acute, subacute, or chronic depending on the timing of onset and presentation.
  • Commonly associated with trauma but can occur spontaneously.

Epidemiology

  • Incidence higher in the elderly due to brain atrophy, which increases the tension on bridging veins.
  • Occurs in approximately 1-5% of all head injuries.
  • Higher incidence in patients on anticoagulant or antiplatelet therapy.
  • Males are more commonly affected than females.
  • Chronic subdural haematomas more common in the elderly.

Aetiology and Pathophysiology

  • Trauma is the most common cause (e.g., falls, motor vehicle accidents).
  • Other causes include coagulopathies, cerebral atrophy, and intracranial hypotension.
  • Tearing of bridging veins leads to slow accumulation of blood in the subdural space.
  • Blood accumulation increases intracranial pressure (ICP), leading to compression of brain structures.
  • Chronic SDH results from repeated minor bleeds, with gradual expansion over weeks to months.

Types

  • Acute SDH: Presents within 72 hours of injury, associated with severe trauma, often seen in younger patients.
  • Subacute SDH: Presents 3 to 21 days post-injury, symptoms may be less severe or fluctuating.
  • Chronic SDH: Presents more than 21 days post-injury, more common in elderly, may present with non-specific symptoms.
  • Spontaneous SDH: Occurs without trauma, often in patients with coagulopathies or on anticoagulants.

Clinical Features 🌡️

Symptoms

  • Headache: Can be severe and persistent, often worsening over time.
  • Altered mental state: Confusion, drowsiness, or unconsciousness.
  • Focal neurological deficits: May include weakness, speech difficulties, or visual disturbances.
  • Seizures: More common in chronic SDH.
  • Symptoms may fluctuate, especially in chronic SDH.

Signs

  • Reduced Glasgow Coma Scale (GCS): Indicates severity of altered consciousness.
  • Papilloedema: May be present due to raised ICP.
  • Hemiparesis: Unilateral weakness, often contralateral to the haematoma.
  • Unequal pupils: Can indicate transtentorial herniation in severe cases.
  • Bradycardia and hypertension: Cushing’s reflex, a late sign of raised ICP.
  • Aphasia: If the dominant hemisphere is involved.

Investigations 🧪

Tests

  • CT Head: Gold standard for diagnosis, shows crescent-shaped, hyperdense area along the convexity of the brain.
  • MRI Head: Useful in subacute and chronic SDH, better at detecting isodense or hypodense bleeds.
  • Coagulation profile: Important in patients with coagulopathies or on anticoagulants.
  • Full blood count (FBC): To check for anaemia or infection.
  • Electrolytes and renal function: Important before surgical intervention.
  • Liver function tests (LFTs): To assess for underlying coagulopathies.

Management 🥼

Management

  • Surgical intervention: Indicated for significant mass effect or neurological deterioration, options include burr hole drainage, craniotomy, or decompressive craniectomy.
  • Conservative management: Considered in small, asymptomatic SDH, with close monitoring and repeat imaging.
  • Correction of coagulopathy: Essential before any surgical intervention; consider reversal of anticoagulants.
  • ICP management: May require medical management of raised ICP (e.g., mannitol, hypertonic saline).
  • Postoperative care: Includes monitoring for recurrence, managing ICP, and rehabilitation.

Complications

  • Recurrence of SDH: Particularly common in chronic SDH, necessitating repeat surgery.
  • Seizures: May occur postoperatively, requiring antiepileptic therapy.
  • Infection: Risk associated with surgical intervention.
  • Cerebral oedema: Can occur post-surgery, requiring ICP management.
  • Permanent neurological deficit: Depending on the extent of brain injury.

Prognosis

  • Prognosis depends on the size of the haematoma, the patient’s age, and neurological status at presentation.
  • Acute SDH has a poorer prognosis compared to chronic SDH, with higher mortality and morbidity.
  • Chronic SDH, when treated appropriately, often has a good prognosis with complete recovery.
  • Neurological recovery may be incomplete in cases of significant brain injury or delayed treatment.

Key Points

  • Subdural haemorrhage is a medical emergency requiring prompt diagnosis and management.
  • Elderly patients and those on anticoagulants are at higher risk.
  • CT scan is the first-line investigation for diagnosis.
  • Early surgical intervention can significantly improve outcomes in acute SDH.
  • Chronic SDH may present with subtle or non-specific symptoms, requiring a high index of suspicion.

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Child health