Subdural Subdural HematomaHematoma

Dr. Monsif Iqbal PGT

Surgery Deptt.P.O.F. Hospital

Case PresentationCase Presentation

PATIENT’s PROFILE:PATIENT’s PROFILE:

Name:Name: M. Riaz M. Riaz Age:Age: 56 yrs. 56 yrs. Sex: Sex: Male Male Address :Address : Attock. Attock. D.O.A:D.O.A: 21-03-2010 21-03-2010 M.O.A:M.O.A: ER ER

PRESENTING COMPLAINTSPRESENTING COMPLAINTS

H/O fall, with head injury – 2 hrsH/O fall, with head injury – 2 hrs DrowsinessDrowsiness VomitingVomiting

PAST HISTORYPAST HISTORY

RTA, with head injury --- 3 years backRTA, with head injury --- 3 years back No significant past medical illness No significant past medical illness

Drug HISTORYDrug HISTORY

No history of warfarin, or aspirin intakeNo history of warfarin, or aspirin intake

PERSONAL HISTORYPERSONAL HISTORY

Non smokerNon smoker No history of drug addiction or No history of drug addiction or

dependence.dependence.

PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:

1.1. GPE:GPE:A middle aged gentleman, lying in bed A middle aged gentleman, lying in bed confused and Drowsyconfused and DrowsyHis vitals are;His vitals are; Pulse: 100/minPulse: 100/min B.P: 130/80 mm of HgB.P: 130/80 mm of Hg Oxygen Sat: 96%Oxygen Sat: 96% Temp: AfebrileTemp: AfebrileRest of GPE unremarkable.Rest of GPE unremarkable.

NEUROLOGICAL NEUROLOGICAL EXAMINATION:EXAMINATION:

GCS 13/15GCS 13/15 Pupils – Bilaterally reactive to lightPupils – Bilaterally reactive to light No Obvious injury on the scalpNo Obvious injury on the scalp Rest of the systemic exam --- Rest of the systemic exam ---

unremarkableunremarkable

Investigations on the day Investigations on the day of admissionof admission

Xrays Skull AP and lateral viewsXrays Skull AP and lateral views Blood CPBlood CP BSRBSR

INVESTIGATIONS:INVESTIGATIONS:1.1. Blood CP: Blood CP:

Hb ---- 13.4 gm/dlHb ---- 13.4 gm/dl TLC ---- 15.5x10TLC ---- 15.5x1033/ul/ul PLT ---- 242x10PLT ---- 242x1033/ul/ul

22. . BSR:BSR:90 mg/dl90 mg/dl

X-ray Skull AP viewX-ray Skull AP view

X-ray skull lateral viewX-ray skull lateral view

ManagementManagement

NPONPO IV fluids (Ringer lactate)IV fluids (Ringer lactate) IV AntibioticsIV Antibiotics Pain KillersPain Killers Input/output recordInput/output record

CT Scan BrainCT Scan Brain

CT Scan BrainCT Scan Brain

Surgical ManagementSurgical Management

Surgical evacuation of the subdural Surgical evacuation of the subdural hematoma under G/Ahematoma under G/A

Subdural HematomaSubdural Hematoma

A subdural hematoma (SDH) is a A subdural hematoma (SDH) is a form of traumatic brain injury in form of traumatic brain injury in which blood gathers between which blood gathers between the dura and the arachnoid.the dura and the arachnoid.

PathophysiologyPathophysiology

Unlike in epidural hematomas, SDH usually results from the tears Unlike in epidural hematomas, SDH usually results from the tears in veins. in veins.

Further expansion due to osmosisFurther expansion due to osmosis

In some subdural bleeds, the arachnoid layer of the meninges is In some subdural bleeds, the arachnoid layer of the meninges is torntorn

Local vasoconstrictorsLocal vasoconstrictors

May be reabsorbed, a subdural hygroma may be formedMay be reabsorbed, a subdural hygroma may be formed

Classification schemeClassification scheme

Acute SDH (upto 7 days)Acute SDH (upto 7 days) Sub acute SDH (7-21 days)Sub acute SDH (7-21 days) Chronic SDH (more than 21 days)Chronic SDH (more than 21 days)

Risk FactorsRisk Factors Extreme of ageExtreme of age AnticogulantsAnticogulants Long term Alcohol AbuseLong term Alcohol Abuse

Clinical Features of SDHClinical Features of SDH A history of recent head injuryA history of recent head injury Loss of consciousness or fluctuating levels of consciousness Loss of consciousness or fluctuating levels of consciousness Irritability Irritability SeizuresSeizures NumbnessNumbness Headache (either constant or fluctuating) Headache (either constant or fluctuating) Dizziness Dizziness Disorientation Disorientation Amnesia Amnesia Weakness or lethargy Weakness or lethargy Nausea or vomitingNausea or vomiting Personality changes Personality changes Inability to speak or slurred speech Inability to speak or slurred speech Ataxia, or difficulty walking Ataxia, or difficulty walking Altered breathing patterns Altered breathing patterns Blurred Vision Blurred Vision

Extradural HematomaExtradural Hematoma Biconvex or lenticularBiconvex or lenticular Temporal or Temporal or

temporoparietaltemporoparietal Middle meningeal arteryMiddle meningeal artery 0.5% of all head injured 0.5% of all head injured

ptspts ““Lucid” interval classicallyLucid” interval classically

Outcome related to status Outcome related to status prior to surgeryprior to surgery

Subdural HematomaSubdural Hematoma Diffuse and concaveDiffuse and concave Entire surface of brainEntire surface of brain

Tearing of bridging veinsTearing of bridging veins 30% of severe head injuries30% of severe head injuries Underlying brain damage Underlying brain damage

more severemore severe Prognosis is worse than Prognosis is worse than

extradural extradural

DiagnosisDiagnosis

It is important that a patient receive It is important that a patient receive medical assessment, including a medical assessment, including a complete neurological examination, after complete neurological examination, after any head trauma. A CT scan will usually any head trauma. A CT scan will usually detect significant subdural hematomas. detect significant subdural hematomas.

8.2. Non-contrast CT Brain 8.2 Non-contrast CT Brain

CT Density 72.9 HUAcute and subacute Subdural Hematoma

8.3a. Non-contrast CT Brain

Chronic Subdural Hematoma

8.4a. Non-contrast CT Brain 8.4b. Non-contrast CT Brain

Subarchnoid hemorrhage

8.4c. Non-contrast CT Brain

8.5 Non-contrast CT Brain

.

8.1. Non-contrast CT Brain 8.1 Non-contrast CT Brain

CT Density 68.6 HUAcute Intracerebral hematoma

TreatmentTreatment

Small Subdural hematomas --- Small Subdural hematomas --- Conservative managementConservative management

Large or Symptomatic --- CraniotomyLarge or Symptomatic --- Craniotomy

Management of Mild Management of Mild Head Injury (GCS 14-15)Head Injury (GCS 14-15)

About 3% of these patients deteriorate unexpectedly, About 3% of these patients deteriorate unexpectedly, resulting in severe neurological dysfunctions unless the resulting in severe neurological dysfunctions unless the decline in mental status is noticed earlydecline in mental status is noticed early

Ideally, a CT scan should be obtained in all head-injury Ideally, a CT scan should be obtained in all head-injury patients, especially if there is a history of more than a patients, especially if there is a history of more than a momentary loss of consciousness, amnesia, or severe momentary loss of consciousness, amnesia, or severe headaches. headaches.

NICE guidelines for CT in NICE guidelines for CT in Head InjuryHead Injury

GCS < 13 at any pointGCS < 13 at any point GCS 13 or 14 at 2 hoursGCS 13 or 14 at 2 hours Focal Neurological deficitFocal Neurological deficit Suspected open, depressed or basal skull fractureSuspected open, depressed or basal skull fracture SeizureSeizure Vomiting > one episodeVomiting > one episode

Urgent CT if none of the above but Urgent CT if none of the above but Age > 65Age > 65 Coagulopathy (e.g. on warfarin)Coagulopathy (e.g. on warfarin) Dangerous mechanism of injury (CT within 8 hours)Dangerous mechanism of injury (CT within 8 hours) Antegrade amnesia > 30 minutesAntegrade amnesia > 30 minutes

Management of Mild Management of Mild Head Injury (GCS 14-15) Head Injury (GCS 14-15)

(cont.)(cont.) At present, skull x-rays are recommended only in At present, skull x-rays are recommended only in

penetrating head injury or when CT scanning is not penetrating head injury or when CT scanning is not immediately availableimmediately available

X-rays of the cervical spine must be obtained if there is X-rays of the cervical spine must be obtained if there is any pain or tenderness.any pain or tenderness.

Management of Moderate Management of Moderate Head Injury(GCS 9-13)Head Injury(GCS 9-13)

Approximately 10% to 20% of these patients Approximately 10% to 20% of these patients deteriorate and lapse into coma. Therefore, they deteriorate and lapse into coma. Therefore, they should be managed like severely head-injured patientshould be managed like severely head-injured patient

They are not routinely intubated. However every They are not routinely intubated. However every precaution should be taken to protect the airwayprecaution should be taken to protect the airway

Management of severe Management of severe Head Injury (GCS 3-8)Head Injury (GCS 3-8)

In a comatose patient (GCS 8 or below) secure and In a comatose patient (GCS 8 or below) secure and maintain the airway by endotracheal intubationmaintain the airway by endotracheal intubation

Moderately hyperventilate the patient to reverse Moderately hyperventilate the patient to reverse hypercarbia, maintaining the PCO2 between 25 and 35 hypercarbia, maintaining the PCO2 between 25 and 35 mm Hgmm Hg

Treat shock aggressively and look for its cause Treat shock aggressively and look for its cause (consider DPL)(consider DPL)

Resuscitate with normal saline, Ringer’s lactate or Resuscitate with normal saline, Ringer’s lactate or similar isotonic solutions without dextrose. Do not use similar isotonic solutions without dextrose. Do not use hypotonic solutions. Avoid both hypovolemia and over hypotonic solutions. Avoid both hypovolemia and over hydration, achieving a euvolemic state.hydration, achieving a euvolemic state.

Perform a neurologic examination after normalizing the Perform a neurologic examination after normalizing the blood pressure and before paralyzing the patent. Avoid blood pressure and before paralyzing the patent. Avoid the use of long-acting paralytic agents.the use of long-acting paralytic agents.

All severe and most modetate head injury patients All severe and most modetate head injury patients require a CT scan to exclude mass lesionsrequire a CT scan to exclude mass lesions

Search for associated injuries. Exclude cervical spine Search for associated injuries. Exclude cervical spine injuries radiographically and clinicallyinjuries radiographically and clinically

Contact a neurosurgeon as early as possible. If a Contact a neurosurgeon as early as possible. If a neurosurgeon is not available at your facility, transfer all neurosurgeon is not available at your facility, transfer all moderately or severely head-injured patientsmoderately or severely head-injured patients

Frequently reassess GCSFrequently reassess GCS

THANKSTHANKS