A subdural hematoma (American spelling) or subdural haematoma (British spelling), also known as a subdural haemorrhage (SDH), is a type of hematoma,

a form of traumatic brain injury. Blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain. Usually resulting from tears in bridging veins which cross the subdural space, subdural hemorrhages may cause an increase in intracranial pressure (ICP), which can cause compression of and damage to delicate brain tissue. Subdural hematomas are often life-threatening when acute. Chronic subdural hematomas, however, have better prognosis if properly managed. In contrast, epidural hematomas are usually caused by tears in arteries, resulting in a build-up of blood between the dura mater and skull.Contents [hide] 1 Classification 2 Signs and symptoms 3 Causes 3.1 Risk factors 4 Pathophysiology 5 Diagnosis 6 Treatment 7 See also 8 References 9 External links [edit] Classification Subdural hematomas are divided into acute, subacute, and chronic, depending on the speed of their onset.[1] Acute subdural hematomas that are due to trauma are the most lethal of all head injuries and have a high mortality rate if they are not rapidly treated with surgical decompression.[2] Acute bleeds often develop after high speed acceleration or deceleration injuries and are increasingly severe with larger hematomas. They are most severe if associated with cerebral contusions.[3] Though much faster than chronic subdural bleeds, acute subdural bleeding is usually venous and therefore slower than the usually arterial bleeding of an epidural hemorrhage. Acute subdural bleeds have a high mortality rate, higher even than epidural hematomas and diffuse brain injuries, because the force (acceleration/deceleration) required to cause them causes other severe injuries as well.[4] The mortality rate associated with acute subdural hematoma is around 60 to 80%.[5] Chronic subdural bleeds develop over a period of days to weeks, often after minor head trauma, though such a cause is not identifiable in 50% of patients.[6] They may not be discovered until they present clinically months or years after a head injury.[7] The bleeding from a chronic bleed is slow, probably from repeated minor bleeds, and usually stops by itself.[8][9] Since these bleeds progress slowly, they present the chance of being stopped before they cause significant damage. Small chronic subdural hematomas, those less than a centimeter wide, have much better outcomes than acute subdural bleeds: in one study, only 22% of patients with chronic subdural bleeds had outcomes worse than "good" or "complete recovery".[3] Chronic subdural hematomas are common in the elderly.[7] [edit] Signs and symptomsHematoma typeEpidural Subdural vte Location Between the skull and the dura Between the dura and the arachnoid

Involved vessel Temperoparietal locus (most likely) - Middle meningeal artery Frontal locus - anterior ethmoidal artery Occipital locus - transverse or sigmoid sinuses Vertex locus - superior sagittal sinus Bridging veins Symptoms Lucid interval followed by unconsciousness Gradually increasing headache and confusion CT appearance Biconvex lens Crescent-shaped

Symptoms of subdural hemorrhage have a slower onset than those of epidural hemorrhages because the lower pressure veins bleed more slowly than arteries. Therefore, signs and symptoms may show up in minutes, if not immediately[10] but can be delayed as much as 2 weeks.[11] If the bleeds are large enough to put pressure on the brain, signs of increased ICP or damage to part of the brain will be present.[3] Other signs and symptoms of subdural hematoma can include any combination of the following: A history of recent head injury Loss of consciousness or fluctuating levels of consciousness Irritability Seizures Pain Numbness Headache (either constant or fluctuating) Dizziness Disorientation Amnesia Weakness or lethargy Nausea or vomiting Loss of appetite Personality changes Inability to speak or slurred speech Ataxia, or difficulty walking Altered breathing patterns Hearing loss or hearing ringing (tinnitus) Blurred Vision Deviated gaze, or abnormal movement of the eyes.[3] [edit] Causes

Subdural hematomas are most often caused by head injury, when rapidly changing velocities within the skull may stretch and tear small bridging veins. Subdural hematomas due to head injury are described as traumatic. Much more common than epidural hemorrhages, subdural hemorrhages generally result from shearing injuries due to various rotational or linear forces.[3][8] Subdural hemorrhage is a classic finding in shaken baby syndrome, in which similar shearing forces classically cause intra- and pre-retinal hemorrhages. Subdural hematoma is also commonly seen in the elderly and in alcoholics, who have evidence of cerebral atrophy. Cerebral atrophy increases the length the bridging veins have to traverse between the two meningeal layers, hence increasing the likelihood of shearing forces causing a tear. It is also more common in patients on anticoagulants, especially aspirin and warfarin. Patients on these medications can have a subdural hematoma with a minor injury. A further cause can be a reduction in cerebal spinal fluid pressure which can create a low pressure in the dura and so cause rupture of the blood vessels [edit] Risk factors Factors increasing the risk of a subdural hematoma include very young or very old age. As the brain shrinks with age, the subdural space enlarges and the veins that traverse the space must travel over a wider distance, making them more vulnerable to tears. This and the fact that the elderly have more brittle veins make chronic subdural bleeds more common in older patients.[6] Infants, too, have larger subdural spaces and are more predisposed to subdural bleeds than are young adults.[3] For this reason, subdural hematoma is a common finding in shaken baby syndrome. In juveniles, an arachnoid cyst is a risk factor for a subdural hematoma.[12] Other risk factors for subdural bleeds include taking blood thinners (anticoagulants), long-term alcohol abuse, and dementia. [edit] Pathophysiology Micrograph of a chronic subdural hematoma, as demonstrated by thin strands of collagen and neovascularization. HPS stain. Collected blood from the subdural bleed may draw in water due to osmosis, causing it to expand, which may compress brain tissue and cause new bleeds by tearing other blood vessels.[6] The collected blood may even develop its own membrane.[13] In some subdural bleeds, the arachnoid layer of the meninges is torn, and cerebrospinal fluid (CSF) and blood both expand in the intracranial space, increasing pressure.[8] Substances that cause vasoconstriction may be released from the collected material in a subdural hematoma, causing further ischemia under the site by restricting blood flow to the brain.[9] When the brain is denied adequate blood flow, a biochemical cascade known as the ischemic cascade is unleashed, and may ultimately lead to brain cell death. The body gradually reabsorbs the clot and replaces it with granulation tissue. [edit] Diagnosis A subdural hematoma demonstrated by CT.

Subdural hematomas occur most often around the tops and sides of the frontal and parietal lobes.[3][8] They also occur in the posterior cranial fossa, and near the falx cerebri and tentorium cerebelli.[3] Unlike epidural hematomas, which cannot expand past the sutures of the skull, subdural hematomas can expand along the inside of the skull, creating a concave shape that follows the curve of the brain, stopping only at the dural reflections like the tentorium cerebelli and falx cerebri. On a CT scan, subdural hematomas are classically crescent-shaped, with a concave surface away from the skull. However, they can have a convex appearance, especially in the early stage of bleeding. This may cause difficulty in distinguishing between subdural and epidural hemorrhages. A more reliable indicator of subdural hemorrhage is its involvement of a larger portion of the cerebral hemisphere since it can cross suture lines, unlike an epidural hemorrhage. Subdural blood can also be seen as a layering density along the tentorium cerebelli. This can be a chronic, stable process, since the feeding system is low-pressure. In such cases, subtle signs of bleeding such as effacement of sulci or medial displacement of the junction between gray matter and white matter may be apparent. A chronic bleed can be the same density as brain tissue (called isodense to brain), meaning that it will show up on CT scan as the same shade as brain tissue, potentially obscuring the finding. [edit] Treatment It is important that a patient receive medical assessment, including a complete neurological examination, after any head trauma. A CT scan or MRI scan will usually detect significant subdural hematomas. Treatment of a subdural hematoma depends on its size and rate of growth. Some small subdural hematomas can be managed by careful monitoring until the body heals itself. Other small subdural hematomas can be managed by inserting a temporary small catheter through a hole drilled through the skull and sucking out the hematoma; this procedure can be done at the bedside. Large or symptomatic hematomas require a craniotomy, the surgical opening of the skull. A surgeon then opens the dura, removes the blood clot with suction or irrigation, and identifies and controls sites of bleeding.[14][15] Postoperative complications include increased intracranial pressure, brain edema, new or recurrent bleeding, infection, and seizure. The injured vessels must be repaired. It is also worth noting, that dependent on the size and deterioration, age of the patient and anaesthetic risk posed, some subdurals will be inoperable and palliative management is the suitable treatment option.A subdural hematoma is a collection of blood on the surface of the brain. Causes Subdural hematomas are usually the result of a serious head injury. When one occurs in this way, it is called an "acute" subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. Subdural hematomas can also occur after a very minor head injury, especially in the elderly. These may go unnoticed for many days to weeks, and are called "chronic" subdural hematomas. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In the elderly, the veins are often already stretched because of brain atrophy (shrinkage) and are more easily injured.

Some subdural hematomas occur without cause (spontaneously). The following increase your risk for a subdural hematoma: Anticoagulant medication (blood thinners, including aspirin) Long-term abuse of alcohol Recurrent falls Repeated head injury Very young or very old age Symptoms Confused speech Difficulty with balance or walking Headache Lethargy or confusion Loss of consciousness Nausea and vomiting Numbness Seizures Slurred speech Visual disturbances Weakness In infants: Bulging fontanelles (the "soft spots" of the baby's skull) Feeding difficulties Focal seizures Generalized tonic-clonic seizure High-pitched cry Increased head circumference Increased sleepiness or lethargy Irritability Persistent vomiting Separated sutures (the areas where growing skull bones join) Exams and Tests Always get medical help after a head injury. Older persons should receive medical care if they shows signs of memory problems or mental decline. An exam should include a complete neurologic exam. Your doctor may order a brain imaging study if you have any of the following symptoms: Confused speech Difficulty with balance or walking Headache Inability to speak Lethargy or confusion Loss of consciousness Nausea and vomiting Numbness Recent congitive decline in an elderly person, even without a history of brain injury Seizures Slurred speech

Visual disturbance Weakness A CT scan or MRI scan likely would be done to evaluate for the presence of a subdural hematoma. Treatment A subdural hematoma is an emergency condition. Emergency surgery may be needed to reduce pressure within the brain. This may involve drilling a small hole in the skull, which allows blood to drain and relieves pressure on the brain. Large hematomas or solid blood clots may need to be removed through a procedure called a craniotomy, which creates a larger opening in the skull. Medicines used to treat a subdural hematoma depend on the type of subdural hematoma, the severity of symptoms, and how much brain damage has occurred. Diuretics and corticosteroids may be used to reduce swelling. Anticonvulsion medications, such as phenytoin, may be used to control or prevent seizures. Outlook (Prognosis) The outlook following a subdural hematoma varies widely depending on the type and location of head injury, the size of the blood collection, and how quickly treatment is obtained. Acute subdural hematomas present the greatest challenge, with high rates of death and injury. Subacute and chronic subdural hematomas have better outcomes in most cases, with symptoms often going away after the blood collection is drained. A period of rehabilitation is sometimes needed to assist the person back to his or her usual level of functioning. There is a high frequency of seizures following a subdural hematoma, even after drainage, but these are usually well controlled with medication. Seizures may occur at the time the hematoma forms, or up to months or years afterward. Possible Complications Brain herniation (pressure on the brain severe enough to cause coma and death) Persistent symptoms such as memory loss, dizziness, headache, anxiety, and difficulty concentrating Seizures Temporary or permanent weakness, numbness, difficulty speaking When to Contact a Medical Professional A subdural hematoma requires emergency medical attention. Call 911 or your local emergency number, or go immediately to an emergency room after a head injury. Spinal injuries often occur with head injuries, so try to keep the person's neck still if you must move him or her before help arrives. Prevention Always use safety equipment at work and play to reduce your risk of a head injury. For example, use hard hats, bicycle or motorcycle helmets, and seat belts. Older individuals should be particularly careful to avoid falls