Initial management of a patient with a suspected subdural haematoma should follow an ABCDE approachto ensure the patient is stable before considering further management options.2
Correction of coagulation studies
All patients on anticoagulation will require reversal agents to prevent further bleeding and extension of the subdural haematoma. Local guidelines for anticoagulation should be followed, with input from haematology if required.
Patients who are found to have a coagulopathy (e.g. prolonged PT, thrombocytopenia) need to be discussed with haematology for advice on appropriate treatments (e.g. fresh-frozen plasma, platelet transfusion).
Patients presenting with acute SDH are at an increased risk of developing seizures and, therefore, may be temporarily commenced on anticonvulsant medication to prevent seizures (e.g. levetiracetam, phenytoin).
The choice of definitive management differs depending on the location, age, size and clinical features of the bleed.
Conservative management may be appropriate if the bleed is small with minimal mass effect (i.e. midline shift or ventricular obstruction).
A trauma craniotomy is typically used in the context of acute SDH with significant mass effect to both evacuate blood and reduce intracranial pressure.
If there is a large bleed and/or a lot of associated cerebral oedema a hemicraniectomy (also known as a decompressive craniectomy) may be performed to prevent brain stem herniation and death due to rising intracranial pressure.
Burr hole craniotomy is typically reserved for the management of chronic SDH. This procedure involves the removal of a small disc-shaped fragment of the skull overlying the SDH to allow the evacuation of the liquified blood. A drain may also be placed for a day or two after to reduce the risk of re-accumulation.
Complications of subdural haematoma include:2,3
Permanent neurological deficits
Recurrent subdural haematoma
A subdural haematoma is defined as a collection of blood between the dura mater and arachnoid mater of the brain.
The most common cause of SDH is trauma, however, other causes include rupture of an arteriovenous malformation and malignancy.
Patients with a suspected SDH should undergo a full neurological examination and have consciousness level assessed using the Glasgow Coma Scale (GCS).
Clinical features of SDH can include headache, nausea, vomiting, signs of raised intracranial pressure and/or focal neurological deficits.
The gold standard investigation for suspected SDH is a non-contrast CT head.
Typical appearances of SDH include a crescent-shapedcollection of blood overlying one of the cerebral hemispheres.
Conservative management may be appropriate if the bleed is small and with minimal mass effect (i.e. midline shift or ventricular obstruction).
A trauma craniotomy is used to manage acute SDH with significant mass effect to both evacuate blood and reduce intracranial pressure.
Hemicraniectomy may be required for large acute SDH to reduce intracranial pressure.
Burr hole craniotomy is typically reserved for the management of chronic SDH.
Complications of SDH include seizures, persistent neurological deficits, recurrent haemorrhage and infection.
Mr Arif Zafar
Brain Injury Group. Brain Injury- The Facts. The BIG Network Ltd. Published in 2018. Available from: [LINK]
NICE Clinical Knowledge Summaries. Head Injury: Assessment and early management. Available from: [LINK]
BMJ Best Practice. Grande AJ. Subdural Haematoma. Available from: [LINK]
Blausen.com staff. Scalp. Wikipedia. Published in 2018. Available from: [LINK]
Case courtesy of Dr Craig Hacking, Radiopaedia.org. Available from: [LINK]
Case courtesy of Dr Jeremy Jones, Radiopaedia.org. Available from: [LINK]