Table of Contents
- Extravasation of blood into the subdural space between the dura and arachnoid membranes
- Most common neurosurgical emergency associated with high morbidity and mortality
- A potentially life-threatening condition requiring urgent surgical evacuation for good clinical outcomes
- mostly traumatic but can be spontaneous
- 50-90% death rate in acute traumatic SDH
- Incidence of traumatic SDH: 11-49%
- After surgical evacuation, recurrent rates as high as 20% in some cases
- Most commonly seen in MVAs in the younger population and from falls in the older age group
- May have a lucid interval in 12-38% of patients
- 35-80% present with GCS ≤8 with a mortality of 55-70%
- Death in patients with GCS 3-15: 30-60%
- Rupture of the bridging veins
- Mostly traumatic but can be spontaneous
- Spontaneous causes of acute SDH: anticoagulants/antiplatelet use, intracranial aneurysmal rupture
- Less common causes: AVMs rupture, cocaine abuse, vascular meningiomas, dural metastases, etc
Figure 1: Acute Subdural Hematoma on CT Brain
Case courtesy of Dr Andrew Ho, Radiopaedia.org, rID: 23274
- Parafalcine and tentorial
- Seen in younger patients with mild traumatic brain injury
- Managed nonoperatively
- Posterior fossa
- Poor outcome
- 50% death rate
- Coagulopathy present
- Associated with low GCS score and occipital fracture
- Seen in ruptured intracranial aneurysms, cancers, anticoagulants use, AIDS, bleeding disorders
- Cerebral blood flow changes
- Reduces significantly instantly after injury due to a decrease in CPP and an increase in ICP
- Cerebral vasoconstriction and defect in autoregulation after brain trauma also contribute to a decrease in CBF
- Hyperemia/hyperperfusion occurs followed by reperfusion injury by oxygen-derived free radicals that are associated with poor clinical outcome
- Occur following traumatic brain injury
- Trigger coagulation pathway increases the likelihood of bleeding
- Affects hemostasis, intracerebral hematoma formation, and expansion that lead to poor clinical outcomes
- Delayed deterioration
- Also known as talk and deteriorate
- Seen in the elderly
- Seen within 6 hours after trauma
- Atrophied brains in the elderly allow more intracranial space to accumulate blood and cerebral edema before clinical deterioration occurs
- Early identification and evacuation of hematoma are important to avoid this phenomenon
- Altered mental status
- Motor weakness
- Epidural hematoma
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Non-contrast CT scan of Head: easily available, Crescent shaped mass, sensitivity nearly 100%
- MRI is superior to CT in identifying small SDH, tentorial, and interhemispheric SDH
- Additional findings like midline shift, brain herniation, associated brain injuries can be seen in brain imaging
- Digital subtraction angiography in non-traumatic acute SDH for suspected rupture of a cerebral aneurysm
- Emergent resuscitation
- Neurosurgical consultation
- Maintenance of airway, breathing, and circulation
- Maintain Pao2> 60mm Hg and MAP> 65mm Hg
- Intubate patient, if unable to maintain the airway
- Rapid sequence intubation to facilitate endotracheal intubation
- Adequate intravenous access
- Reversal of anticoagulation to avoid hematoma expansion
- Intracranial pressure monitoring and treatment
- Elevate head of bed to 300
- Intracranial pressure Treatment
- ICP treatment only recommended if the patient is a surgical candidate and on the way to surgical intervention
- Brief Hyperventilation to maintain PaCO2 of 32-36 mm Hg (max 4 hours)
- Osmolar therapy with Mannitol 1 to 1.5g/kg and/or 30 to 120ml of 23.4% Hypertonic saline (on the way to surgical suite)
- Seizure prophylaxis: Phenytoin/fosphenytoin or Levetiracetam
- Blood pressure and cerebral perfusion pressure management
- Maintain CPP above 60 mm Hg in adults and 40-65mm Hg in children
- Fentanyl- 25 to 200 mcg/hr
- Remi-fentanyl- 0.5 to 2 mcg/kg/min
- Propofol- 5mcg/kg/min followed by increase in 5-10mcg/kg/min until adequate sedation is achieved
- Temperature control
- Maintain normothermia by acetaminophen
- Glucose control
- Maintain blood glucose level 120-180 mg/dl
- Avoid hyperglycemia using insulin sliding scales
- Stress ulcer prophylaxis
- PPIs preferred over H2 blockers, sucralfate
Indications for emergent surgery
- A rapid decline in neurological status Mydriasis: unilateral or bilateral Extensor posture Midline shift in CT Head > 5mmHematoma size in CT Head > 10mm
- Neurosurgical evacuation under general anesthesia
- Brain herniation
- Prognosis depends upon age, neurological condition, radiological appearance, the timing of neurosurgery, associated brain injuries, extracranial injuries, and postoperative care
- 25-50% of cases are comatose after the trauma
- 12-38% of cases undergo gradual neurological deterioration followed by coma a few hours after the trauma
- Overall bad prognosis in serious trauma to the brain parenchyma, associated brain edema and/or herniation
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Center for Neuro-Restoration at Cleveland Clinic Main Campus