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Chapter 110. Management of Subdural and Extradural Hematomas

Lisa E. Vianna, DO; Roopa Kohli-Seth, MD

NB: For the management of craniotomy or burr hole for SDH or EDH, see chapter on Craniotomy (Chapter 101).

Figure 110-1. Anatomy of Subdural and Epidural Hematomas
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Reproduced from Waxman SG: Clinical Neuroanatomy. 26th Edition. Figure 12-25 and 12-26. Available at: www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

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Subdural versus Extradural Hematoma
SubduralExtradural
Anatomic location
  • Under dura mater
  • Bridging veins between the brain and dura tear
  • Outside of dura mater
  • Can occur in the spine (epidural hematoma)
  • Tears in small arteries (predominantly the middle meningeal artery)
  • Higher pressure in arteries leads to more rapid bleeding; often in temporal or temporal–parietal region
BleedingVenousArterial
Time course
  • Acute/subacute (minutes to hours)
  • or chronic (days to weeks)
Acute
Causes
  • Head injury/trauma
  • Malignancy
  • Spontaneous
Head trauma
Risk factors
  • Extremes of age (very old or very young)
  • Use of anticoagulants (clopidogrel [Plavix], Aspirin, warfarin [Coumadin]; dabigatran [Pradaxa])
  • Chronic alcohol use/abuse
  • Frequent and recurrent falls
Symptoms
  • Adults
    • Headache
    • Balance disturbances
    • Weakness or paresthesias
    • Seizures
    • Slurred or confused speech
    • Nausea/vomiting
    • Change in level of consciousness (mild delirium to obtundation)
  • Infants
    • Bulging fontanelles/change in head circumference
    • Seizures
    • Irritability or lethargy
    • Vomiting or difficulty feeding
  • Headache—often intense/severe
  • Change in mental status—unconsciousness; can have a “lucid interval” with rapid decline thereafter (“talk-and-deteriorate”)
  • Cranial nerve III (oculomotor)—fixed and dilated pupil on the same side as the injury/bleed; eye will appear inferior and laterally deviated (unopposed CN VI)
  • Abnormal cerebral posturing
  • Weakness of the extremities on the same side as the lesion
  • Loss of vision on the contralateral side
  • Respiratory arrest possible (due to transtentorial or uncal herniation—compression on the medulla)
  • Imaging appearance (noncontrast CT brain or MRI)
  • Classically appears crescent shaped with concave surface away from the skull
    • Extra-axial collections with increased attenuation
    • When large enough, may cause effacement of the sulci and midline shift
    • Can cross suture lines
  • May have a convex appearance particularly in the early stages of bleeding but distinguished from epidural bleeds by ability to cross suture lines
Often appears as a biconvex lens
TreatmentIndications for surgery:
  • SDH with thickness greater than 10 mm or midline shift greater than 5 mm
  • Comatose patient (GCS < 9) with lesion less than 10mm or midline shift less than 5 mm, if GCS decreased by 2 or more points between time of injury and hospital presentation
  • Patient presents with an asymmetric/fixed or dilated pupil
  • ICP exceeds 20 mm Hg (normal ICP ˜ 5–15 mm Hg)
Surgical procedures: Procedure chosen determined by the surgeon based on the size/location of the lesion and the anatomic access required of the underlying pathology.
  • Burr hole—or keyhole craniotomy; small dime size; minimally invasive procedure
  • Craniotomy—removal of a larger portion of skull
  • Shunts (subdural to peritoneal)—particularly chronic subdural
    • more often in infants and young children; rarely in adults
Surgical removal of blood.
  • Burr hole—less often ...

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