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
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.
Subdural versus Extradural Hematoma
- 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
- Acute/subacute (minutes to hours)
- or chronic (days to weeks)
- Head injury/trauma
- 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
- Balance disturbances
- Weakness or paresthesias
- Slurred or confused speech
- Change in level of consciousness (mild delirium to obtundation)
- Bulging fontanelles/change in head circumference
- 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|
|Treatment||Indications for surgery: |
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.
- 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)
- 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 utilized due to small access and limited visibility
- Procedure chosen determined by the surgeon, the size/location of the lesion and the anatomic access required ...
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