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Subdural
Hematoma
PATHOPHYSIOLOGY, IMAGING, AND MANAGEMENT
Definition 2
Subdural Hematoma (SDH) refers to bleeding
between the dura mater and arachnoid mater. It
occurs due to rupture of bridging veins and can
be classified based on timing: acute, subacute,
and chronic.
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Classification 4
• Acute SDH: <72 hours after injury,
hyperdense on CT.
• Subacute SDH: 3–21 days, isodense on CT.
• Chronic SDH: >21 days, hypodense on CT,
often in elderly or alcoholics.
Classification 5
Pathophysiology 6
Acute subdural hematoma:
• Caused by tearing of bridging veins between the
cortex and dural sinuses.
• Increased intracranial pressure (ICP) may develop.
Chronic subdural hematoma:
• The first etiology is associated with an acute
subdural hematoma
• The second etiology involves a subdural hygroma, a
collection of CSF in the subdural space caused by the
splitting of the dural border cell layer at points of
tension between the dura mater and arachnoid mater
Pathophysiology 7
Clinical Features 8
• Headache, confusion, or drowsiness.
• Focal neurological deficits (hemiparesis).
• Altered consciousness or coma in severe
cases.
• Elderly: symptoms may develop gradually.
Imaging Characteristics 9
CT scan findings:
• Crescent-shaped hyperdensity (acute SDH).
• Iso- or hypodensity in subacute/chronic SDH.
• Midline shift or compression of ventricles
indicates mass effect.
Acute subdural 1
0
hematoma
Chronic subdural 1
1
hematoma
Imaging Characteristics 1
2
Imaging Characteristics 1
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Management 1
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• Small and asymptomatic: Observation and
repeat imaging.
• Symptomatic or large SDH:
- Burr hole drainage (especially chronic SDH).
- Craniotomy for evacuation (acute SDH).
• Control of intracranial pressure and supportive
care.
Management of ASDH 1
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Indications for surgery:
1. ASDH with thickness > 10 mm or midline shift (MLS) > 5
mm (on CT) should be evacuated regardless of GCS
2. ASDH with thickness < 10 mm and MLS < 5 mm should
surgical evacuation if:
a) GCS drops by ≥ 2 points from injury to admission
b) and/or the pupils are asymmetric or fixed and dilated
c) and/or ICP is > 20 mm Hg
3. monitor ICP in all patients with ASDH and GCS < 9
Management of ASDH 1
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Surgery methods:
• ASDH meeting the above criteria for surgery should be
evacuated via craniotomy with or without bone flap removal
and duraplasty (a large craniotomy flap is often required to
evacuate the thick coagulum and to gain access to possible
bleeding sites)
Timming of surgery: patients operated within 4 hrs of injury
had 30% mortality, compared to 90% mortality if surgery was
delayed > 4 hrs
Management of CSDH 1
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Management of CSDH 1
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1. Seizure prophylaxis: used by some.
2. Coagulopathies (including anticoagulation & antiplatelet therapy)
should be reversed
3. Treatment of the hematoma
a) indications:
● symptomatic lesions (usually > 1 cm maximal thickness or MLS >=
5mm). Symptoms include: focal deficit, mental status changes,
seizures, severe H/A…
● or progressive increase in size on serial imaging (CT or MRI scans)
b) treatment options:
● surgical evacuation of the hematoma: numerous methods employed
(see below)
● endovascular embolization of the middle meningeal artery
Management of CSDH 1
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Surgical options:
1. placing two burr holes, and irrigating through and through with
tepid saline until the fluid runs clear
2. single “large” burr hole with irrigation and aspiration:
3. single burr hole drainage with placement of a subdural drain,
maintained for 24–48 hrs (removed when output becomes
negligible)
4. twist drill craniostomy: see below
5. craniotomy with excision of subdural membrane
Burr hole drainage and 2
0
mini craniectomy
Burr hole drainage and 2
1
mini craniectomy
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2
2
3
2
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