Subdur al

Hematoma

Dr. Monsif Iqbal

PGT
Surgery Deptt.
P.O.F. Hospital
Case
Presentation
PATIENT’s PROFILE:

 Name: M. Riaz
 Age: 56 yrs.
 Sex: Male
 Address : Attock.
 D.O.A: 21-03-2010
 M.O.A: ER
PRESENTING COMPLAINTS

 H/O fall, with head injury – 2 hrs

 Drowsiness
 Vomiting
PAST HISTORY

 RTA, with head injury --- 3 years back

 No significant past medical illness
Drug HISTORY

 No history of warfarin, or aspirin intake

PERSONAL HISTORY

 Non smoker
 No history of drug addiction or
dependence.
PHYSICAL EXAMINATION:
1. GPE:
A middle aged gentleman, lying in bed
confused and Drowsy
His vitals are;
 Pulse: 100/min
 B.P: 130/80 mm of Hg
 Oxygen Sat: 96%
 Temp: Afebrile
Rest of GPE unremarkable.
NEUROLOGICAL
EXAMINATION:
 GCS 13/15
 Pupils – Bilaterally reactive to light
 No Obvious injury on the scalp
 Rest of the systemic exam ---
unremarkable
Investigations on the
day of admission
 Xrays Skull AP and lateral views
 Blood CP
 BSR
 INVESTIGATIONS:
1. Blood CP:
 Hb ---- 13.4 gm/dl
 TLC ---- 15.5x103/ul
 PLT ---- 242x103/ul
2. BSR:90 mg/dl
X-ray Skull AP view
X-ray skull lateral view
 Management

 NPO
 IV fluids (Ringer lactate)
 IV Antibiotics
 Pain Killers
 Input/output record
CT Scan Brain
CT Scan Brain
Surgical Management

 Surgical evacuation of the subdural

hematoma under G/A
Subdural Hematoma

 A subdural hematoma (SDH)

is a form of traumatic brain
injury in which blood gathers
between the dura and the
arachnoid.
 Pathophysiology
 Unlike in epidural hematomas, SDH usually results from the tears
in veins.

 Further expansion due to osmosis

 In some subdural bleeds, the arachnoid layer of the meninges is

torn

 Local vasoconstrictors

 May be reabsorbed, a subdural hygroma may be formed

Classification scheme

 Acute SDH (upto 7 days)

 Sub acute SDH (7-21 days)
 Chronic SDH (more than 21 days)
Risk Factors
 Extreme of age
 Anticogulants
 Long term Alcohol Abuse
 Clinical Features of
 A history of recent head SDH
injury
 Loss of consciousness or fluctuating levels of consciousness
 Irritability
 Seizures
 Numbness
 Headache (either constant or fluctuating)
 Dizziness
 Disorientation
 Amnesia
 Weakness or lethargy
 Nausea or vomiting
 Personality changes
 Inability to speak or slurred speech
 Ataxia, or difficulty walking
 Altered breathing patterns
 Blurred Vision
Extradural Hematoma
 Biconvex or lenticular
 Temporal or
temporoparietal
 Middle meningeal artery
 0.5% of all head injured
pts
 “Lucid” interval classically
 Outcome related to status
prior to surgery
Subdural Hematoma
 Diffuse and concave
 Entire surface of brain
 Tearing of bridging veins
 30% of severe head
injuries
 Underlying brain damage
more severe
 Prognosis is worse than
extradural
 Diagnosis

 It is important that a patient receive

medical assessment, including a
complete neurological examination, after
any head trauma. A CT scan will usually
detect significant subdural hematomas.
8.2. Non-contrast CT Brain 8.2 Non-contrast CT Brain
Acute and subacute Subdural CT Density 72.9 HU
Hematoma
 8.3a. Non-contrast CT Brain

Chronic Subdural Hematoma

8.4a. Non-contrast CT Brain 8.4b. Non-contrast CT Brain 8.4c. Non-contrast CT Brain

Subarchnoid hemorrhage
 .

8.5 Non-contrast CT Brain

8.1. Non-contrast CT Brain 8.1 Non-contrast CT Brain
CT Density 68.6 HU
Acute Intracerebral hematoma
 Treatment

 Small Subdural hematomas ---

Conservative management
 Large or Symptomatic --- Craniotomy
 Management of Mild
Head Injury (GCS
14-15)
 About 3% of these patients deteriorate unexpectedly,
resulting in severe neurological dysfunctions unless the
decline in mental status is noticed early

 Ideally, a CT scan should be obtained in all head-injury

patients, especially if there is a history of more than a
momentary loss of consciousness, amnesia, or severe
headaches.
NICE guidelines for CT
in Head Injury
 GCS < 13 at any point
 GCS 13 or 14 at 2 hours
 Focal Neurological deficit
 Suspected open, depressed or basal skull fracture
 Seizure
 Vomiting > one episode
Urgent CT if none of the above but
 Age > 65
 Coagulopathy (e.g. on warfarin)
 Dangerous mechanism of injury (CT within 8 hours)
 Antegrade amnesia > 30 minutes
 Management of Mild
Head Injury (GCS
14-15) (cont.)
 At present, skull x-rays are recommended only in
penetrating head injury or when CT scanning is not
immediately available

 X-rays of the cervical spine must be obtained if there is

any pain or tenderness.
 Management of
Moderate Head
Injury(GCS 9-13)
 Approximately 10% to 20% of these patients
deteriorate and lapse into coma. Therefore, they
should be managed like severely head-injured patient

 They are not routinely intubated. However every

precaution should be taken to protect the airway
Management of severe
Head Injury (GCS 3-8)
 In a comatose patient (GCS 8 or below) secure and
maintain the airway by endotracheal intubation
 Moderately hyperventilate the patient to reverse
hypercarbia, maintaining the PCO2 between 25 and 35
mm Hg
 Treat shock aggressively and look for its cause
(consider DPL)
 Resuscitate with normal saline, Ringer’s lactate or
similar isotonic solutions without dextrose. Do not use
hypotonic solutions. Avoid both hypovolemia and over
hydration, achieving a euvolemic state.
 Perform a neurologic examination after normalizing the
blood pressure and before paralyzing the patent. Avoid
the use of long-acting paralytic agents.
 All severe and most modetate head injury patients
require a CT scan to exclude mass lesions
 Search for associated injuries. Exclude cervical spine
injuries radiographically and clinically
 Contact a neurosurgeon as early as possible. If a
neurosurgeon is not available at your facility, transfer
all moderately or severely head-injured patients
 Frequently reassess GCS
THANKS