Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content ++ 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 HematomasGraphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt)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. ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintSubdural versus Extradural HematomaSubduralExtraduralAnatomic locationUnder dura materBridging veins between the brain and dura tearOutside of dura materCan 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 regionBleedingVenousArterialTime courseAcute/subacute (minutes to hours)or chronic (days to weeks)AcuteCausesHead injury/traumaMalignancySpontaneousHead traumaRisk factorsExtremes of age (very old or very young)Use of anticoagulants (clopidogrel [Plavix], Aspirin, warfarin [Coumadin]; dabigatran [Pradaxa])Chronic alcohol use/abuseFrequent and recurrent fallsSymptomsAdultsHeadacheBalance disturbancesWeakness or paresthesiasSeizuresSlurred or confused speechNausea/vomitingChange in level of consciousness (mild delirium to obtundation)InfantsBulging fontanelles/change in head circumferenceSeizuresIrritability or lethargyVomiting or difficulty feedingHeadache—often intense/severeChange 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 posturingWeakness of the extremities on the same side as the lesionLoss of vision on the contralateral sideRespiratory 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 skullExtra-axial collections with increased attenuationWhen large enough, may cause effacement of the sulci and midline shiftCan cross suture linesMay have a convex appearance particularly in the early stages of bleeding but distinguished from epidural bleeds by ability to cross suture linesOften appears as a biconvex lensTreatmentIndications for surgery: SDH with thickness greater than 10 mm or midline shift greater than 5 mmComatose 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 presentationPatient presents with an asymmetric/fixed or dilated pupilICP 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 procedureCraniotomy—removal of a larger portion of skullShunts (subdural to peritoneal)—particularly chronic subdural more often in infants and young children; rarely in adultsSurgical removal of blood. Burr hole—less often utilized due to small access and limited visibilityCraniotomy—preferredProcedure chosen determined by the surgeon, the size/location of the lesion and the anatomic access required ... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. What is MyAccess? Create a FREE MyAccess profile to: Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessAnesthesiology 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessAnesthesiology Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options