History

Fact Explanation
Introduction Accumulation of blood in between dura and arachnoid causing haematoma from bridging vessels on the surface of the brain. This can be divide into acute and chronic. Acute Sub dural hemotomas are sudden onset of haematoma usually following a severe trauma. Usually this is associated with underlying brain damage and marked reduction of cerebral blood flow. Prognosis will not good with this type. Chronic Sub dural hemotomas occur few days to weeks after a trauma. Majority will be asymptomatic (as small haemorrhages will absorb) and this is associated with atrophy of the brain matter. This is common among males, elderly patients and alcoholic patients[1][2].
History of impaired consciousness and abnormal behavior patient will have fluctuating level of consciousness, insidious physical or interlectual slowing, sleepiness, personality changes and unsteadiness. All of these symptoms are due to the cerebral involvement following Sub dural hemotoma. Irritation by leaked blood, vasospasm with bleeding causing ischemia, cerebral oedema and increased intracranial pressure can leds to these symptoms[3][4][5].
Headache Patient will develop sudden on set headache. The headache is usually associated with nausea and vomiting . the headache can be exacerbate with coughtin and straining like situations which increases the pressure in side the body[6][7].
Development of seizures With the head injury or secondary to sub dural haematoma can cause brain damage causing neuronal damage. So this can be associated with abnormal neuronal transmission of the impulses causing seizures[8][9].
History of head trauma Trauma to head will give an aetiology for the condition. Sudden severe head trauma can cause huge acute sub dural haematoma and repeated head injuries( eg: in gender based violence, in child abuse) will leads to chronic sub dural haematoma[3][5].
History of alcohol misuse Long term alcohol misuse leads to brain arophy and causes stretching of the blood vessels over the surface of the brain. This facilitate the bridging of vessels. Also patients can face several head injuries under the influence of alcohol[10][11].
Drug history of anticoagulants/ anti platelets Drugs like waferin, enoxaparin, aspirin and increases the bleeding tendency[12][13].
Past history of hypertension/ dyslipidaemia. These factors are acquired risk factors for weakening the blood vessels and development of Sub dural hemotoma[14][15].
Past history of aneurysm/ arteriovenous malformations Spontaneous subdural hematoma can be associated with aneurysms/arteriovenous malformations. Following the rupture of the aneurysms or bleeding from arteriovenous malformations, blood can pass throught the parenchyma of the brain/subarachnoid space causing subdural hematoma[16][17].
past hitory of primary tumour in brain/ evidence of metastases to the brain Primary/ secondary tumors of the brain can give symptoms of space occupying lesion. Also tumours can bleed and cause subdural hematomas[11][18].
Recent history of head surgery Post surgical bleeding can cause sub dural haematomas[15][19].
History of being abused Being a victim for an abuse (eg: Shaken baby syndrome) or violence will cause repeated injuries. This can lead to chronic sub dural haematomas[3][5][20].
Past history of epilepsy In epilepsy patient is at high risk of fall and getting injuries[3][5].
Recent history of lumbar puncture/ spinal anesthesia or insertion of a lumboperitoneal shunt Following these conditions there will be intracranial hypotension which can ultimately leads to the development of sub dural haematoma. The exact mechanism is not clear but it is thought to be bridging vessels on the surface of the brain following down ward displacement of the brain with intracranial hypotension [21][22][23].
References
  1. GUTHKELCH AN. Infantile Subdural Haematoma and its Relationship to Whiplash Injuries Br Med J [online] 1971 May 22, 2(5759):430-431 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1796151
  2. ADHIYAMAN V, ASGHAR M, GANESHRAM K, BHOWMICK B. Chronic subdural haematoma in the elderly Postgrad Med J [online] 2002 Feb, 78(916):71-75 [viewed 28 October 2014] Available from: doi:10.1136/pmj.78.916.71
  3. JAYAWANT S, PARR J. Outcome following subdural haemorrhages in infancy Arch Dis Child [online] 2007 Apr, 92(4):343-347 [viewed 28 October 2014] Available from: doi:10.1136/adc.2005.084988
  4. NORDSTRöM A, NORDSTRöM P. Cognitive Performance in Late Adolescence and the Subsequent Risk of Subdural Hematoma: An Observational Study of a Prospective Nationwide Cohort PLoS Med [online] 2011 Dec, 8(12):e1001151 [viewed 28 October 2014] Available from: doi:10.1371/journal.pmed.1001151
  5. GABAEFF SC. Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome West J Emerg Med [online] 2011 May, 12(2):144-158 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099599
  6. DE NORONHA RJ, SHARRACK B, HADJIVASSILIOU M, ROMANOWSKI C. Subdural haematoma: a potentially serious consequence of spontaneous intracranial hypotension J Neurol Neurosurg Psychiatry [online] 2003 Jun, 74(6):752-755 [viewed 28 October 2014] Available from: doi:10.1136/jnnp.74.6.752
  7. SCHWEIGER V, ZANCONATO G, LONATI G, BAGGIO S, GOTTIN L, POLATI E. Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section Case Rep Obstet Gynecol [online] 2013:253408 [viewed 28 October 2014] Available from: doi:10.1155/2013/253408
  8. OHNO K, MAEHARA T, ICHIMURA K, SUZUKI R, HIRAKAWA K, MONMA S. Low incidence of seizures in patients with chronic subdural haematoma. J Neurol Neurosurg Psychiatry [online] 1993 Nov, 56(11):1231-1233 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC489829
  9. KRISHNAN P, KARTIKUEYAN R. Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature J Pediatr Neurosci [online] 2013, 8(2):177-179 [viewed 28 October 2014] Available from: doi:10.4103/1817-1745.117869
  10. GODLEWSKI B, ZAPALOWICZ K. Atypical presentations of chronic subdural hematomas J Neurosci Rural Pract [online] 2014, 5(4):328-329 [viewed 28 October 2014] Available from: doi:10.4103/0976-3147.139963
  11. MOON W, JOO W, CHOUGH J, PARK H. Spontaneous Spinal Subdural Hematoma Concurrent with Cranial Subdural Hematoma J Korean Neurosurg Soc [online] 2013 Jul, 54(1):68-70 [viewed 28 October 2014] Available from: doi:10.3340/jkns.2013.54.1.68
  12. AKINS PT, AXELROD YK, JI C, CIPOREN JN, ARSHAD ST, HAWK MW, GUPPY KH. Cerebral venous sinus thrombosis complicated by subdural hematomas: Case series and literature review Surg Neurol Int [online] :85 [viewed 28 October 2014] Available from: doi:10.4103/2152-7806.113651
  13. PAN A, ROGERS AG, HILL NC, HENTELEFF PD. Bilateral Subdural Hematoma Complicating Phenylindanedione (Danilone) Therapy Can Med Assoc J [online] 1962 Nov 24, 87(21):1119-1120 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1849828
  14. LOUIS L, BAIR N, BANJAC S, DWEIK RA, TONELLI AR. Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs Pulm Circ [online] 2012, 2(4):518-521 [viewed 28 October 2014] Available from: doi:10.4103/2045-8932.105041
  15. KOLLATOS C, KONSTANTINOU D, RAFTOPOULOS S, KLIRONOMOS G, MESSINIS L, ZAMPAKIS P, PAPATHANASOPOULOS P, PANAGIOTOPOULOS V. Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma Hippokratia [online] 2011, 15(4):370-372 [viewed 28 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876859
  16. WANG HS, KIM SW, KIM SH. Spontaneous Chronic Subdural Hematoma in an Adolescent Girl J Korean Neurosurg Soc [online] 2013 Mar, 53(3):201-203 [viewed 28 October 2014] Available from: doi:10.3340/jkns.2013.53.3.201
  17. HOU K, LI CG, ZHANG Y, ZHU BX. The Surgical Treatment of Three Young Chronic Subdural Hematoma Patients with Different Causes J Korean Neurosurg Soc [online] 2014 Apr, 55(4):218-221 [viewed 28 October 2014] Available from: doi:10.3340/jkns.2014.55.4.218
  18. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 28 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  19. UTKU U, GüLER S, YALNıZ E, ÜNLü E. Subdural and Cerebellar Hematomas Which Developed after Spinal Surgery: A Case Report and Review of the Literature Case Rep Neurol Med [online] 2013:431261 [viewed 28 October 2014] Available from: doi:10.1155/2013/431261
  20. BLUMENTHAL I. Shaken baby syndrome Postgrad Med J [online] 2002 Dec, 78(926):732-735 [viewed 28 October 2014] Available from: doi:10.1136/pmj.78.926.732
  21. KIM HJ, CHO YJ, CHO JY, LEE DH, HONG KS. Acute Subdural Hematoma Following Spinal Cerebrospinal Fluid Drainage in a Patient with Freezing of Gait J Clin Neurol [online] 2009 Jun, 5(2):95-96 [viewed 29 October 2014] Available from: doi:10.3988/jcn.2009.5.2.95
  22. HASSEN GW, KALANTARI H. Diplopia from Subacute Bilateral Subdural Hematoma after Spinal Anesthesia West J Emerg Med [online] 2012 Feb, 13(1):108-110 [viewed 29 October 2014] Available from: doi:10.5811/westjem.2011.8.6872
  23. KIM BW, JUNG YJ, KIM MS, CHOI BY. Chronic Subdural Hematoma after Spontaneous Intracranial Hypotension : A Case Treated with Epidural Blood Patch on C1-2 J Korean Neurosurg Soc [online] 2011 Sep, 50(3):274-276 [viewed 29 October 2014] Available from: doi:10.3340/jkns.2011.50.3.274

Examination

Fact Explanation
General examination In general examination should look for anaemia, level of hydration, presence of drowsiness, confusion or coma with Glasgow Coma Score[1][2]. .
Signs suggestive of increased intra cranial pressure Patient will have nausea, vomiting with neurological symptoms. on fundoscopic examination there will be papilledema[3][4].
Neurological examination Neurologic examination reveals alteration in mental status (confusion/ drowsiness), development of seizures, hemiplegia, paresthesias, visual disturbance. Recent asymmetrical findings in neurological examination will suggest cerebral patology[1][5].
Evidence of blunt head trauma Can look for any wounds, bruises over the head, any signs of base of skull fracture ( like bilateral periorbital oedaema, Battle’s sign, cerebrospinal fluid rhinorrhoea or otorrhoea Haemotympanum or bleeding from ear)[6][7].
Evidence of increased bleeding tendency multiple bruising patches, patechiae, mucosal bleeding (gum bleeding, epistaxis, haematuria, pv bleeding)[8][9].
Examination of the back To assess any evidence (Eg: scars/ plasters over the lower lumbar area) of recently done lumbar puncture/ saddle block[11][12][13].
References
  1. MCKENZIE KG. A SURGICAL AND CLINICAL STUDY OF NINE CASES OF CHRONIC SUB-DURAL HAEMATOMA Can Med Assoc J [online] 1932 May, 26(5):534-544 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC402332
  2. CAMERON MM. Chronic subdural haematoma: a review of 114 cases. J Neurol Neurosurg Psychiatry [online] 1978 Sep, 41(9):834-839 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC493164
  3. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 27 October 2014] Available from: doi:10.4103/1793-5482.116390
  4. LEWIN W. Acute Subdural and Extradural Haematoma in Closed Head Injuries: Hunterian lecture delivered at the Royal College of Surgeons of England on 23rd February, 1949 Ann R Coll Surg Engl [online] 1949 Oct, 5(4):240-274 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2238383
  5. ADHIYAMAN V, ASGHAR M, GANESHRAM K, BHOWMICK B. Chronic subdural haematoma in the elderly Postgrad Med J [online] 2002 Feb, 78(916):71-75 [viewed 27 October 2014] Available from: doi:10.1136/pmj.78.916.71
  6. ASHKENAZI E, POMERANZ S. Nystagmus as the presentation of tentorial incisure subdural haematoma. J Neurol Neurosurg Psychiatry [online] 1994 Jul, 57(7):830-831 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073024
  7. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 27 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441
  8. JAGATSINH Y. Cauda equina syndrome: A rare complication in intensive care Indian J Orthop [online] 2009, 43(3):309-311 [viewed 27 October 2014] Available from: doi:10.4103/0019-5413.50873
  9. HARRISON C, KHAIR K, BAXTER B, RUSSELL-EGGITT I, HANN I, LIESNER R. Hermansky-Pudlak syndrome: infrequent bleeding and first report of Turkish and Pakistani kindreds Arch Dis Child [online] 2002 Apr, 86(4):297-301 [viewed 27 October 2014] Available from: doi:10.1136/adc.86.4.297
  10. BLUMENTHAL I. Shaken baby syndrome Postgrad Med J [online] 2002 Dec, 78(926):732-735 [viewed 28 October 2014] Available from: doi:10.1136/pmj.78.926.732
  11. KIM HJ, CHO YJ, CHO JY, LEE DH, HONG KS. Acute Subdural Hematoma Following Spinal Cerebrospinal Fluid Drainage in a Patient with Freezing of Gait J Clin Neurol [online] 2009 Jun, 5(2):95-96 [viewed 29 October 2014] Available from: doi:10.3988/jcn.2009.5.2.95
  12. HASSEN GW, KALANTARI H. Diplopia from Subacute Bilateral Subdural Hematoma after Spinal Anesthesia West J Emerg Med [online] 2012 Feb, 13(1):108-110 [viewed 29 October 2014] Available from: doi:10.5811/westjem.2011.8.6872
  13. KIM BW, JUNG YJ, KIM MS, CHOI BY. Chronic Subdural Hematoma after Spontaneous Intracranial Hypotension : A Case Treated with Epidural Blood Patch on C1-2 J Korean Neurosurg Soc [online] 2011 Sep, 50(3):274-276 [viewed 29 October 2014] Available from: doi:10.3340/jkns.2011.50.3.274

Differential Diagnoses

Fact Explanation
Ischemic Stroke Ischaemic stroke is fairly a silent paralysis. The patient may complain sudden onset hemiparesis, mouth deviation, vision loss or slurred speech which is usually not associated with headache, seizures or loss of consciousness. Typical patients will be older generation with vascular co-morbidity such as hypertension, smoking, diabetes mellitus and hyperlipidaemia. Imaging with non contrast CT or MRI will show the area of ischaemia[3][4].
Dementia Dementia is consists of progressive deficit in cognitive impairment. With the time there will be increasing forgetfulness, increasing incompetence in daily living activities, changing the personality and impairing the cognitive function. Imaging studies will differentiate the both conditions [7][8].
Other Space occupying lesion (eg: tumours) In these instances the clinical symptoms would be more gradual onset rather than symptoms in sub dural haemorrhages. In brain tumors the will be recent history of headache with are characterized by early morning worsening, worsening with straining and relief by vomiting. Other features such as altered behavior, late onset seizures and progressive hemiparesis would suggest a space occupying lesion. Imaging with contrast enhanced CT and MRI would demonstrate the lesion[5][6].
Uraemia In uraemia patients will present with nausea, vomitiong, loss of appetite, reduced level of consciousness. These symptoms can gragually develop with the severity of uraemia. Patient will also have features suggestive of acute/ chronic renal failure (generalized body swelling, anaemia, reduced urine output). Blood urea will be high with other impaired renal function tests[11][12].
Hepatic encephalopathy Patients will develop altered mood/ behaviour, sleep disturbances, drowsiness, slurring of speech and confusion like symptoms following Hepatic encephalopathy secodary to liver failure. This will be associated with features suggestive of liver failure (jaundice, ascitis, coaggulopathy) and impaired liver function tests[13][14].
Subarachnoid hemorrhage Bleeding into the sub arachnoid space called Sub Arachnoid hemorrhage. This is associated with sudden severe headache, nausea/ vomiting and focal neurological signs. Imaging with CT brain will differentiate both conditions[15][16].
Meningitis Meningitis could be septic of aseptic. The differentiation of sub dural haemorrhage from meningitis is important for the management. In meningitis the headache will not be that much severe like in sub arachnoid haemorrhage. Usually the patient will be febrile with headache, photo phobia and features of meningism. Fundoscopy may reveal papiloedema or blurred macular margins. Inflammatory markers would be elevated in meningitis. Imaging with CT brain and Cerebro spinal fluid analysis may differentiate two conditions[1][2].
Parkinson disease This is a neurological condition occur in elderly people, associated with degeneration of the substantia nigra. There will be tremor, rigidity and bradykinesia. Presence of lowy bodies can be seen in pathological investigations of these patients. Some times this can be associated with strokes, and dementia. Imaging studies will be helpful in differentiating the conditions[9][10].
References
  1. ANJAY MA, ANOOP P. Tuberculous meningitis: more evidence for protective effect of BCG Arch Dis Child [online] 2007 Mar, 92(3):277 [viewed 22 October 2014] Available from: doi:10.1136/adc.2006.109363
  2. EL BASHIR H, LAUNDY M, BOOY R. Diagnosis and treatment of bacterial meningitis Arch Dis Child [online] 2003 Jul, 88(7):615-620 [viewed 22 October 2014] Available from: doi:10.1136/adc.88.7.615
  3. JICKLING GC, XU H, STAMOVA B, ANDER BP, ZHAN X, TIAN Y, LIU D, TURNER RJ, MESIAS M, VERRO P, KHOURY J, JAUCH EC, PANCIOLI A, BRODERICK JP, SHARP FR. Signatures of cardioembolic and large vessel ischemic stroke Ann Neurol [online] 2010 Nov, 68(5):681-692 [viewed 22 October 2014] Available from: doi:10.1002/ana.22187
  4. STANKOWSKI JN, GUPTA R. Therapeutic Targets for Neuroprotection in Acute Ischemic Stroke: Lost in Translation? Antioxid Redox Signal [online] 2011 May 15, 14(10):1841-1851 [viewed 22 October 2014] Available from: doi:10.1089/ars.2010.3292
  5. GAGE JT, VANCE EA, HILDENBRAND PG, MATTISON T. Brain lesion and AIDS Proc (Bayl Univ Med Cent) [online] 2000 Oct, 13(4):424-429 [viewed 22 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312248
  6. MESHKINI A, SHAHZADI S, ALIKHAH H, NAGHAVI-BEHZAD M. Role of stereotactic biopsy in histological diagnosis of multiple brain lesions Asian J Neurosurg [online] 2013, 8(2):69-73 [viewed 22 October 2014] Available from: doi:10.4103/1793-5482.116374
  7. ANDRADE C, RADHAKRISHNAN R. The prevention and treatment of cognitive decline and dementia: An overview of recent research on experimental treatments Indian J Psychiatry [online] 2009, 51(1):12-25 [viewed 25 October 2014] Available from: doi:10.4103/0019-5545.44900
  8. DESCHENES CL, MCCURRY SM. Current Treatments for Sleep Disturbances in Individuals With Dementia Curr Psychiatry Rep [online] 2009 Feb, 11(1):20-26 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649672
  9. COUNE PG, SCHNEIDER BL, AEBISCHER P. Parkinson's Disease: Gene Therapies Cold Spring Harb Perspect Med [online] 2012 Apr, 2(4):a009431 [viewed 25 October 2014] Available from: doi:10.1101/cshperspect.a009431
  10. CHENG HC, ULANE CM, BURKE RE. Clinical Progression in Parkinson's Disease and the Neurobiology of Axons Ann Neurol [online] 2010 Jun, 67(6):715-725 [viewed 25 October 2014] Available from: doi:10.1002/ana.21995
  11. BLUMENKRANTZ MJ, SHAPIRO DJ, SWENDSEID ME, KOPPLE JD. Histidine supplementation for treatment of anaemia of uraemia. Br Med J [online] 1975 Jun 7, 2(5970):530-533 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1673315
  12. MILLER TE, STEWART E. Host immune status in uraemia. I. Cell-mediated immune mechanisms. Clin Exp Immunol [online] 1980 Jul, 41(1):115-122 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1536926
  13. BLEIBEL W, AL-OSAIMI AM. Hepatic Encephalopathy Saudi J Gastroenterol [online] 2012, 18(5):301-309 [viewed 25 October 2014] Available from: doi:10.4103/1319-3767.101123
  14. TOGHILL PJ. Treatment of hepatic encephalopathy. Postgrad Med J [online] 1969 Mar, 45(521):227-229 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466809
  15. PERRY JJ, STIELL IG, SIVILOTTI ML, BULLARD MJ, LEE JS, EISENHAUER M, SYMINGTON C, MORTENSEN M, SUTHERLAND J, LESIUK H, WELLS GA. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study BMJ [online] 2010:c5204 [viewed 22 October 2014] Available from: doi:10.1136/bmj.c5204
  16. AL-SHAHI R, WHITE PM, DAVENPORT RJ, LINDSAY KW. Subarachnoid haemorrhage BMJ [online] 2006 Jul 29, 333(7561):235-240 [viewed 22 October 2014] Available from: doi:10.1136/bmj.333.7561.235

Investigations - for Diagnosis

Fact Explanation
CT scan This will show the typical crescent shape collection of blood. If the haematoma is large there will be associated midline shift towards the normal side. The density of the haematoma will give an idea about the duration of the duration of it (eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense) Acoordin to NICE guidelines for computerised tomography (CT) in head injury -Glasgow Coma Score (GCS) < 13 at any point -GCS 13 or 14 at 2 hours -Focal neurological deficit -Suspected open, depressed or basal skull fracture -Seizure -Vomiting > one episode Urgent CT head scan if none of the above but: - Age > 65 -Coagulopathy (e.g. on warfarin) -Dangerous mechanism of injury (CT within 8 hours) -Antegrade amnesia > 30 min (CT within 8 hours) [1][2]
MRI scan This will be useful in assessing the underlying brain damage following trauma[3][4].
References
  1. PARK HR, LEE KS, SHIM JJ, YOON SM, BAE HG, DOH JW. Multiple Densities of the Chronic Subdural Hematoma in CT Scans J Korean Neurosurg Soc [online] 2013 Jul, 54(1):38-41 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2013.54.1.38
  2. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441
  3. LEE KS, SHIM JJ, YOON SM, DOH JW, YUN IG, BAE HG. Acute-on-Chronic Subdural Hematoma: Not Uncommon Events J Korean Neurosurg Soc [online] 2011 Dec, 50(6):512-516 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2011.50.6.512
  4. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.116390

Investigations - Fitness for Management

Fact Explanation
FBC This will be useful in looking for platelet count, haemoglobin level and WBC count when preparing the patient for invasive procedures and surgeries[1][2].
Clotting profile with PT/ INR, APTT These test also useful to assess the clotting status of the patient[3][4].
Renal function tests like serum electrolylres, serum creatinine, blood urea Assessment of the renal function of the patient is useful during imaging and pre operatively to assess the fitness for surgery[5][6].
ECG These will be helpful in pre-operative fitness assessment specially in elderly poppulation[7][8].
Chest X ray This will give an idea about lung status and this use before surgical procedures to assess the fitness[9][10].
Blood grouping and cross matching This need to be done pre operatively and blood should be preserved[11].
References
  1. ABDALLAH C. Considerations in perioperative assessment of valproic acid coagulopathy J Anaesthesiol Clin Pharmacol [online] 2014, 30(1):7-9 [viewed 25 October 2014] Available from: doi:10.4103/0970-9185.125685
  2. HOU K, LI CG, ZHANG Y, ZHU BX. The Surgical Treatment of Three Young Chronic Subdural Hematoma Patients with Different Causes J Korean Neurosurg Soc [online] 2014 Apr, 55(4):218-221 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2014.55.4.218
  3. MISHRA A, OJHA BK, CHANDRA A, SRIVASTAVA C, SINGH SK. Giant unusual shaped chronic subdural hematoma in a patient with untreated congenital hydrocephalus Asian J Neurosurg [online] 2011, 6(2):121-122 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.92183
  4. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.116390
  5. MERKLER AE, SAINI V, KAMEL H, STIEG PE. Preoperative Steroid Use and the Risk of Infectious Complications After Neurosurgery Neurohospitalist [online] 2014 Apr, 4(2):80-85 [viewed 25 October 2014] Available from: doi:10.1177/1941874413510920
  6. MULLIGAN P, RAORE B, LIU S, OLSON JJ. Neurological and functional outcomes of subdural hematoma evacuation in patients over 70 years of age J Neurosci Rural Pract [online] 2013, 4(3):250-256 [viewed 25 October 2014] Available from: doi:10.4103/0976-3147.118760
  7. FREEMAN WK, GIBBONS RJ. Perioperative Cardiovascular Assessment of Patients Undergoing Noncardiac Surgery Mayo Clin Proc [online] 2009 Jan, 84(1):79-90 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664575
  8. LEE BR, LEE JR, KIM MS. Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report Korean J Anesthesiol [online] 2014 Feb, 66(2):160-163 [viewed 25 October 2014] Available from: doi:10.4097/kjae.2014.66.2.160
  9. CHUGH AP, GANDHOKE CS, MOHITE AG, KHEDKAR BV. Primary angiosarcoma of the skull: A rare case report Surg Neurol Int [online] :92 [viewed 25 October 2014] Available from: doi:10.4103/2152-7806.134365
  10. YAMADA Y, INAMASU J, MORIYA S, OGURI D, HASEGAWA M, ABE M, HIROSE Y. Subdural Hematoma Caused by Epithelioid Angiosarcoma Originating from the Skull Head Neck Pathol [online] , 7(2):159-162 [viewed 25 October 2014] Available from: doi:10.1007/s12105-012-0389-9
  11. MADHUGIRI VS, ARIMAPPAMAGAN A, CHANDRAMOULI BA. Traumatic epidural and subdural hematomas and extensive brain infarcts in a patient with pial arteriovenous malformation: Mechanisms underlying clinical and radiological findings Asian J Neurosurg [online] 2012, 7(4):210-213 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.106657

Investigations - Followup

Fact Explanation
FBC During follow up this is useful to assess the associated anaemia condition and need of blood transfusion. Also can identify any associated infections[1][2].
CT scanning This is useful in assessing the complications associated with Sub Arachnoid hemorrhage like rebleeding and hydrocephalus[3][4].
Serum electrolytes Electrolyte disturbances like hyponatraemia can cause drosiness, loss of consiousness and seizures. As this can be commonly occur in elderly patients, excusion of those possibilities will be important[5][6].
EEG This will be useful in monitoring the patients brain function and also will useful during the management (eg if patient is giving barbiturates to reduce intracranial pressure the dose need to be guided by EEG monitoring as it is associated with respiratory and metabolic complications)[7][8].
References
  1. HOU K, LI CG, ZHANG Y, ZHU BX. The Surgical Treatment of Three Young Chronic Subdural Hematoma Patients with Different Causes J Korean Neurosurg Soc [online] 2014 Apr, 55(4):218-221 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2014.55.4.218
  2. ABDALLAH C. Considerations in perioperative assessment of valproic acid coagulopathy J Anaesthesiol Clin Pharmacol [online] 2014, 30(1):7-9 [viewed 25 October 2014] Available from: doi:10.4103/0970-9185.125685
  3. PARK HR, LEE KS, SHIM JJ, YOON SM, BAE HG, DOH JW. Multiple Densities of the Chronic Subdural Hematoma in CT Scans J Korean Neurosurg Soc [online] 2013 Jul, 54(1):38-41 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2013.54.1.38
  4. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441
  5. MONTAIN SJ, CHEUVRONT SN, SAWKA MN. Exercise associated hyponatraemia: quantitative analysis to understand the aetiology Br J Sports Med [online] 2006 Feb, 40(2):98-105 [viewed 25 October 2014] Available from: doi:10.1136/bjsm.2005.018481
  6. FARRELL DJ, BOWER L. Fatal water intoxication J Clin Pathol [online] 2003 Oct, 56(10):803-804 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770067
  7. JONES SC, BAMFORD JM, HEATH J, BRADEY N, HEATLEY RV. Multiple forms of epileptic attack secondary to a small chronic subdural haematoma. BMJ [online] 1989 Aug 12, 299(6696):439-441 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1837297
  8. VAN GOMPEL JJ, STEAD SM, GIANNINI C, MEYER FB, MARSH WR, FOUNTAIN T, SO E, COHEN-GADOL A, LEE KH, WORRELL GA. Phase I trial: safety and feasibility of intracranial electroencephalography using hybrid subdural electrodes containing macro- and microelectrode arrays Neurosurg Focus [online] 2008 Sep, 25(3):E23 [viewed 25 October 2014] Available from: doi:10.3171/FOC/2008/25/9/E23

Investigations - Screening/Staging

Fact Explanation
Clotting profile with PT /INR, APTT As Sub dural hemotoma can be associated with bleeding problems, Clotting profile will useful in screening for any associated clotting defect[1][2].
CT scan As there will be changes indensity of the haematoma with the time(eg: acute/upto 10 days- hyperdense, 10 days to 2 weeks- isodense, chronic/ more than 2 weeks haematoma- hypodense), this can be use to stage the Sub dural hemotoma either as acute or chronic[3][4].
References
  1. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.116390
  2. MISHRA A, OJHA BK, CHANDRA A, SRIVASTAVA C, SINGH SK. Giant unusual shaped chronic subdural hematoma in a patient with untreated congenital hydrocephalus Asian J Neurosurg [online] 2011, 6(2):121-122 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.92183
  3. PARK HR, LEE KS, SHIM JJ, YOON SM, BAE HG, DOH JW. Multiple Densities of the Chronic Subdural Hematoma in CT Scans J Korean Neurosurg Soc [online] 2013 Jul, 54(1):38-41 [viewed 25 October 2014] Available from: doi:10.3340/jkns.2013.54.1.38
  4. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441

Management - General Measures

Fact Explanation
Resuscitation and stabilization of the patient According to the patients condition, especially in an acute sub dural haematoma, initial steps need stabilization of the patient including ABC management. Airway of the patient should be secured. Airway secretions during seizures, defective swallowing ability can lead to airway obstruction. Secretions should be sucked out and can be temporally maintained with an oral airway, when there is persistent obstruction and high risk of aspiration immediate intubation with endotracheal tube is beneficial. Breathing of the patient can be affected by increased intracranial pressure causing respiratory center suprresion. In these kind of instances immediate intubation with ventilatory support should be given in an ICU setup. Even though the blood pressure would be elevated during initial phase circulatory collapse could occur due to carciac center inhibition due to increased intracranial pressure, so adequate fluid resuscitation with inotrop support may be needed. When the patients are having seizures it should be actively managed and prevented because it could further impede the cerebral perfusion[1][2].
Close monitoring Close monitoring of the patient's general condition, blood pressure, pulse rate, respiratory rate, pupillary reaction, Glasgow coma scale need to be done[3][4].
Medical management of raised intracranial pressure In medical management of raised intracranial pressure, Position of the patient need to be done with head up 30º this will avoid obstruction of venous drainage from head[5][7]. Sedation of the patient can be done either wit or with out muscle relaxant. This will calm down the patient[6][7]. Patient should be ventilated and will need to incubate according to patients condition to maintain normocapnia 4.5–5.0 kPa[5]. Diuretics such as furosemide, mannitol will reduce raised intracranial pressure temporarily by reducing cerebral swelling[8][9]. If the patients develops seizures tratment with anti convulsant medication with phenytoin, phenobarbital will be needed. This is important as seizures will increase the brain metabolic rate[5][8]. If patient is having fever, anti pyratics can be given such as paracetamol. As hperthermia will increase the brain metabolic rate, maintaining normothermia is important[5][10][11]. Fluid and electrolyte balance need to be maintaining with close monitoring as in severely brain-injured patients are susceptible to disturbances of sodium haemostasis (eg:diabetes insipidus and syndrome of inappropriate antidiuretic hormone)[12][13].
Control hypertension If patient is having hypertension, adequate antihypertensive agents (eg; beta blockers, calcium channel blockers) need to be given while continuously monitoring the patients blood pressure[5][14].
If the patient is comatose Intubated and mechanically ventilation will be needed. Nutrition supplymentation and hydration can be done via nasogastric tubes or via parenteral rout[1][2].
Catheretization This will be important in assessing the urine out put in both pre oparative (to minimize further falls) and post operative periods[1][2].
Prevent Deep vein thrombosis During pre operative period and post operatively Prevention of deep vein thrombosis is very important. Compression stockings, intermittent pneumatic compression of the calves will be useful in here[14][15].
Anti emetics Anti emetics like promethazine will be useful in the presence of recurrent vomiting[16][17].
Patient education The patient and the family members should be thoroughly educated regarding the condition, probable aetiology, complications associated with, investigation and treatment options available and prognosis. During the resuscitation phase in high risk patients (eg: acute severe Sub dural haematoma) the family should be emphasized regarding the illness and risk on life as well as the care of disabled patient following recovery. This should include the hydration, nutrition, prevention of DVT, prevention of bed sores and first aid care during seizures[5][7].
Preventive measures First need to be identify the aetiological cause for the development of sub dural haematoma. ( eg: If the sub dural haematoma is secondary to head trauma, identify any associated vision problems, difficulty in walking, use of alcohol, high risk works like occupation, cognitive imparement) These conditions should be address and correct/ minimize as far as possible[2][5].
Neurorehabilitation In considering the long-term management of the brain-injured patient, Neurorehabilitation will be use ful in improving the quality of life. For this the help of medical, nursing, physiotherapy and speech and occupational therapy teams will be important[14][18].
References
  1. SCHWEIGER V, ZANCONATO G, LONATI G, BAGGIO S, GOTTIN L, POLATI E. Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section Case Rep Obstet Gynecol [online] 2013:253408 [viewed 25 October 2014] Available from: doi:10.1155/2013/253408
  2. LOGAN SM, BELL GW, LEONARD JC. Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report J Athl Train [online] 2001, 36(4):433-436 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441
  3. MEGUINS LC, SAMPAIO GB, ABIB EC, ADRY RA, ELLAKKIS RF, RIBEIRO FW, MASET ÂL, DE MORAIS DF. Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): a case report J Med Case Rep [online] :153 [viewed 25 October 2014] Available from: doi:10.1186/1752-1947-8-153
  4. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 25 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  5. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 25 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  6. CHOTAI S, KIM JH, KIM JH, KWON TH. Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension Asian J Neurosurg [online] 2013, 8(2):112-115 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.116390
  7. BRODEUR BR, BOYER M, CHARLEBOIS I, HAMEL J, COUTURE F, RIOUX CR, MARTIN D. Identification of Group B Streptococcal Sip Protein, Which Elicits Cross-Protective Immunity Infect Immun [online] 2000 Oct, 68(10):5610-5618 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101513
  8. WALL M. Idiopathic Intracranial Hypertension Neurol Clin [online] 2010 Aug, 28(3):593-617 [viewed 25 October 2014] Available from: doi:10.1016/j.ncl.2010.03.003
  9. UPADHYAY P, TRIPATHI VN, SINGH RP, SACHAN D. Role of hypertonic saline and mannitol in the management of raised intracranial pressure in children: A randomized comparative study J Pediatr Neurosci [online] 2010, 5(1):18-21 [viewed 25 October 2014] Available from: doi:10.4103/1817-1745.66673
  10. HADDAD SH, ARABI YM. Critical care management of severe traumatic brain injury in adults Scand J Trauma Resusc Emerg Med [online] :12 [viewed 25 October 2014] Available from: doi:10.1186/1757-7241-20-12
  11. MAK CH, LU YY, WONG GK. Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage Vasc Health Risk Manag [online] 2013:353-359 [viewed 25 October 2014] Available from: doi:10.2147/VHRM.S34046
  12. VLADISLAV P, BERNARD G, CHIBBARO S. Chronic subdural haematoma management: an iatrogenic complication. Case report and literature review BMJ Case Rep [online] :bcr1220115397 [viewed 25 October 2014] Available from: doi:10.1136/bcr.12.2011.5397
  13. TISDALL M, CROCKER M, WATKISS J, SMITH M. Disturbances of sodium in critically ill adult neurologic patients: a clinical review J Neurosurg Anesthesiol [online] 2006 Jan, 18(1):57-63 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513666
  14. TSENG JH, TSENG MY, LIU AJ, LIN WH, HU HY, HSIAO SH. Risk Factors for Chronic Subdural Hematoma after a Minor Head Injury in the Elderly: A Population-Based Study Biomed Res Int [online] 2014:218646 [viewed 25 October 2014] Available from: doi:10.1155/2014/218646
  15. RYAN CG, THOMPSON RE, TEMKIN NR, CRANE PK, ELLENBOGEN RG, ELMORE JG. Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center J Trauma Acute Care Surg [online] 2012 Nov, 73(5):1348-1354 [viewed 25 October 2014] Available from: doi:10.1097/TA.0b013e31826fcb30
  16. PARK IB, MOON SY, KIM YY, KWON YE, LEE JH. Acute-on-chronic subdural hematoma by spinal anesthesia in a patient with undiagnosed chronic subdural hematoma -A case report- Korean J Anesthesiol [online] 2011 Jul, 61(1):75-78 [viewed 25 October 2014] Available from: doi:10.4097/kjae.2011.61.1.75
  17. GABAEFF SC. Challenging the Pathophysiologic Connection between Subdural Hematoma, Retinal Hemorrhage and Shaken Baby Syndrome West J Emerg Med [online] 2011 May, 12(2):144-158 [viewed 25 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099599
  18. JAYAWANT S, PARR J. Outcome following subdural haemorrhages in infancy Arch Dis Child [online] 2007 Apr, 92(4):343-347 [viewed 25 October 2014] Available from: doi:10.1136/adc.2005.084988

Management - Specific Treatments

Fact Explanation
Surgical intervention The surgical intervention for the SDH is dependent on the the type of SDH weather acute or chronic, timing, size of the haematoma, location and the patient's medical fitness for the surgery. In acute SDH evacuation of the haematoma via craniotomy is indicated when the CT shows a haematoma more than 5 mm thickness and when the the patient shows a neurological impairment or focal weakness. If the above indications are there surgery would be carried out irrespective of the GCS level. Creniectomy is also n practice when the increased intracranial pressure is anticipated. In chronic SDH evacuation is indicated when the patient is symptomatic, when there is a significant mass effect on CT or when the CT shows and expanding lesion with normal neurology. The surgery for chronic SDH is usually via bur hole aspiration. In some instances the craniotomy is also indicated. Contra indications for surgery No specific contra indications for the surgery but has to be applied in to the individual patient. When the patient is having massive haematoma with marked neurological deficit with poor out come usually the surgery will not be indicated. On the other hand acute SDH with less than 5 mm thickness without much neurological impairment and mass effect also will be monitored with tomography. In chronic SDH also asymptomatic haematomas without much pressure effects will be monitored with out active intervention. [1][2][3][4]
References
  1. BHAT AR, KIRMANI AR, WANI MA. Decompressive craniectomy with multi-dural stabs - A combined (SKIMS) technique to evacuate acute subdural hematoma with underlying severe traumatic brain edema Asian J Neurosurg [online] 2013, 8(1):15-20 [viewed 25 October 2014] Available from: doi:10.4103/1793-5482.110275
  2. CINCU R, DE ASIS LORENTE F, RIVERO D, EIRAS J, ARA JR. Spontaneous subdural hematoma of the thoracolumbar region with massive recurrent bleed Indian J Orthop [online] 2009, 43(4):412-415 [viewed 25 October 2014] Available from: doi:10.4103/0019-5413.49383
  3. RANGEL-CASTILLO L, GOPINATH S, ROBERTSON CS. Management of Intracranial Hypertension Neurol Clin [online] 2008 May, 26(2):521-541 [viewed 29 October 2014] Available from: doi:10.1016/j.ncl.2008.02.003
  4. FRAZIER CH. THE SURGICAL MANAGEMENT OF CHRONIC SUBDURAL HEMATOMA Ann Surg [online] 1935 Feb, 101(2):671-689 [viewed 29 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1392044