Acute subdural haematoma

Theory

Acute subdural haematoma occurs generally in elderly patients following a closed head injury.

Age related atrophy of the cerebral cortex occurs, widening the space between the dura mater and the arachnoid mater.

Following a head injury, bleeding can occur in the bridging veins between the cortex and the venous sinuses in the brain. These sit in the arachnoid space.

Bleeding here develops quickly into a haematoma between the dura and the arachnoid mater. This causes a rise in intracranial pressure and can result in midline shift and possibly death from tentorial herniation and coning, although generally the pressure is not high enough in the venous system to allow this to occur.

Immediate intern management

If trauma/following a fall – ABCs and cervical spine immobilisation.

Targeted history and examination.

Suspect the diagnosis.

Sit patient to 30 degrees head up.
Nil orally, oxygen by mask.
Obtain IV access and commence gentle IV fluids.
Measure and record Glasgow Coma Score (GCS).

If GCS falls to <8, patients can not protect airway and require intubation. Urgently notify senior staff/call Code Blue.

Commence regular neurological observations:
- every 15 minutes for two hours
- every 30 minutes for two hours
- every one hour for four hours.
Organise urgent CT scan of brain.
Notify parent registrar and surgical registrar.

Clinical features

History

Closed head trauma/fall
Asymptomatic
Confusion
Altered/fluctuating conscious state
Physical and intellectual slowing
Sleepiness
Headache
Change in personality
Unsteadiness

Examination

GCS
Neurological examination
- Focal deficits/enlarging pupil

Observation

Changing/deteriorating level of consciousness or GCS

Investigations

CT scan brain

Concave haematoma that does not cross midline

Hyperintense <10 days
Isointense = 10–12 days
Hypointense >12 days

GCS – Glasgow Coma Score

Best observed ability	Score
Eyes
Open spontaneously	4
Open to voice	3
Open to pain	2
Closed	1
Verbal
Normal and appropriate	5
Speaks sentences but confused	4
Speaks words	3
Makes unintelligible sounds	2
Non-verbal	1
Motor
Obeys commands	6
Localises to pain	5
Withdraws to pain	4
Flexion to pain response	3
Extends to pain	2
No response	1

Risk factors

Elderly
Alcoholics
Patients on anticoagulants
Patients prone to falls (can occur after a fall in hospital)
Sedatives/opiates
Patients with head trauma
Acute delirium
Altered conscious state

Definitive management

Urgent neurosurgical referral is required

Urgent neurosurgical decompression

Acute <10–12 days
- Requires craniotomy and evacuation of haematoma
Chronic >12 days
- Can undergo burr hole drainage of liquefied clot

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