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‡ Introduction
‡ Classification
‡ Signs & Symptoms
‡ Causes
‡ Pathophysiology
‡ Diagnosis
‡ Treatment
‡ Craniotomy
‡ Complications
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‡ A u
  
  , also known as a
u
   (SDH), is a type of
hematoma, a form of traumatic brain injury in
which blood gathers within the outermost
meningeal layer, between the dura matter, which
adheres to the skull, and the arachnoid mater
enveloping the brain.
‡ Usually results from tears in bridging veins that
cross the subdural space.
‡ subdural hemorrhages may cause an
increase in intracranial pressure (ICP),
which can cause compression of and
damage to delicate brain tissue. Subdural
hematomas are often life-threatening
when acute, but chronic subdural
hematomas are usually not deadly if
treated.
‡ In contrast, epidural hematomas are
usually caused by tears in arteries,
resulting in a buildup of blood between the
dura and the skull.
 p
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 V
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‡ Subdural hematomas are divided into

(depending on their speed of onset )
¦ acute
¦ chronic,
 ›V

‡ Acute subdural
hematomas that are due
to trauma are the lethal
of all head injuries and
have a high mortality
rate if they are not
rapidly treated with
surgical decompression.
 atiology of acute SDH

ÔHead trauma
ÔCoagulopathy or medical anticoagulation (eg,
warfarin [Coumadin], heparin, hemophilia,
liver disease, thrombocytopenia)
ÔNontraumatic intracranial hemorrhage due to
cerebral aneurysm, arteriovenous
malformation, or tumor (meningioma or dural
metastases)
ÔPostsurgical (craniotomy, CSF shunting)
ÔIntracranial hypotension (eg, after lumbar
puncture, lumbar CSF leak, lumboperitoneal
shunt, spinal epidural anesthesia

ÔChild abuse or shaken baby syndrome (in the

pediatric age group)

ÔSpontaneous or unknown (rare)

‡ Acute bleeds develop after high speed
acceleration or deceleration injuries and are
increasingly severe with larger hematomas.
‡ They are most severe if associated with
cerebral contusions.

‡ Though much faster than chronic

subdural bleeds, acute subdural bleeding
is usually venous and therefore slower
than the usually arterial bleeding of an
epidural hemorrhage.
‡ Acute subdural bleeds have a high mortality
rate, higher even than diffuse brain injuries,
because the force (acceleration/deceleration)
required to cause them cause other severe
injuries as well.

‡ The mortality rate associated with acute

subdural hematoma is around 60 to 80%.
V

V
 Chronic subdural bleeds develop over the period
of days to weeks, often after minor head trauma.
 They may not be discovered until they present
clinically months or years after a head injury.
 The bleeding from a chronic bleed is slow,
probably from repeated minor bleeds, and
usually stops by itself.
 Since these bleeds progress slowly, they
present the chance of being stopped before they
cause significant damage.
 atiology of Chronic SDH

ÔHead trauma (may be relatively mild,

eg, in older individuals with cerebral
atrophy)
ÔAcute SDH, with or without surgical
intervention
ÔSpontaneous or idiopathic
 Small chronic subdural hematomas, those
less than a centimeter wide, have much
better outcomes than acute subdural
bleeds.
 Only 22% of patients with chronic subdural
bleeds had outcomes worse than "good"
or "complete recovery".
 Chronic subdural hematomas are
common in the elderly.
 p 



r Symptoms of subdural hemorrhage have a
slower onset than those of epidural
hemorrhages because the lower pressure
veins bleed more slowly than arteries.

r Therefore, signs and symptoms may show

up in minutes, if not immediately but can
be delayed as much as 2 weeks
Signs and Symptoms of subdural hematoma can include
any combination of the following:

‡ Loss of consciousness or fluctuating levels of

consciousness
‡ Irritability
‡ Seizures
‡ Pain
‡ Numbness
‡ Headache (either constant or fluctuating)
‡ Dizziness
‡ Disorientation
‡ Amnesia
‡ Weakness or lethargy
‡ Nausea or vomiting
‡ Loss of appetite
‡ Personality changes
‡ Inability to speak or slurred speech
‡ Ataxia, or difficulty walking
‡ Altered breathing patterns
‡ Hearing loss or hearing ringing (tinnitus)
‡ Blurred Vision
‡ Deviated gaze, or abnormal movement of the
eyes
 
‡ Subdural hematomas are most often caused by
head injury, when rapidly changing velocities
within the skull may stretch and tear small
bridging veins.

‡ Subdural hemorrhages generally result from

shearing injuries due to various rotational or
linear forces.

‡ Subdural hemorrhage is a classic finding in

shaken baby syndrome which show shearing
forces
‡ Subdural hematoma is also commonly
seen in the elderly and in alcoholics, who
have evidence of cerebral atrophy.
Cerebral atrophy increases the length the
bridging veins have to traverse between
the two meningeal layers, hence
increasing the likelihood of shearing forces
causing a tear
‡ It is also more common in patients on
anticoagulants, especially aspirin and
warfarin. Patients on these medications
can have a subdural hematoma with a
minor injury.

‡ A further cause can be a reduction in

cerebral spinal fluid pressure which can
create a low pressure in the dura and so
cause rupture of the blood vessels.

 p
 —
—  

‡ Collected blood from the subdural bleed may
draw in water due to osmosis, causing it to
expand, which may compress brain tissue and
cause new bleeds by tearing other blood
vessels.

‡ In some subdural bleeds, the arachnoid layer of

the meninges is torn, and cerebrospinal fluid
(CSF) and blood both expand in the intracranial
space, increasing pressure
‡ Substances that cause vasoconstriction may be
released from the collected material in a
subdural hematoma, causing further ischemia
under the site by restricting blood flow to the
brain.

‡ When the brain is denied adequate blood flow, a

biochemical cascade known as the ischemic
cascade is unleashed, and may ultimately lead
to brain cell death.
p  p
A subdural hematoma demonstrated by CT.
‡ Subdural hematomas occur most often around
the tops and sides of the frontal and parietal
lobes.They also occur in the posterior cranial
fossa, and near the falx cerebri and tentorium
cerebelli.

‡ Unlike aDH, subdural hematomas can expand

along the inside of the skull, creating a concave
shape that follows the curve of the brain,
stopping only at the dural reflections like the
tentorium cerebelli and falx cerebri
‡ On a CT scan, subdural hematomas are
classically crescent-shaped, with a concave
surface away from the skull. However, they can
have a convex appearance, especially in the
early stage of bleeding.

‡ A more reliable indicator of subdural

hemorrhage is its involvement of a larger portion
of the cerebral hemisphere since it can cross
suture lines, unlike an epidural hemorrhage
‡ Subdural blood can also be seen as a layering
density along the tentorium cerebelli.

‡ In chronic bleed, subtle signs of bleeding such

as effacement of sulci or medial displacement of
the junction between gray matter and white
matter may be apparent.

‡ A chronic bleed can be the same density as

brain tissue (called isodense to brain), meaning
that it will show up on CT scan as the same
shade as brain tissue, potentially obscuring the
finding.




‡ Treatment of a subdural hematoma depends on
its size and rate of growth.
‡ Some small subdural hematomas can be
managed by careful monitoring until the body
heals itself.
‡ Other small subdural hematomas can be
managed by inserting a
temporary small catheter
through a hole drilled
through the skull and
sucking out the hematoma;
this procedure can be done
at the bedside.
‡ Large or symptomatic hematomas require
a craniotomy, the surgical opening of the
skull. It involves opening the dura, removal
of the blood clot with suction or irrigation,
and identifying and controling sites of
bleeding.
V 
 
‡ Craniotomy is any bony opening that is cut
into the skull. A section of skull, called a
bone flap, is removed to access the brain
underneath.
‡ There are many types of craniotomies, which are named
according to the area of skull to be removed .
‡ Typically the bone flap is replaced. If the bone flap is not
replaced, the procedure is called a craniectomy

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‡ Craniotomies are also named according to
their size and complexity.
‡ Small dime-sized craniotomies are called
burr holes or keyhole craniotomies.
‡ Sometimes stereotactic frames, image-
guided computer systems, or endoscopes
are used to precisely direct instruments
through these small holes.
Burr holes or keyhole craniotomies are used for
minimally invasive procedures to:

insert a shunt into the ventricles to drain

cerebrospinal fluid (hydrocephalus)
insert a deep brain stimulator to treat Parkinson
Disease
insert an intracranial pressure (ICP) monitor
remove a small sample of abnormal tissue
(needle biopsy)
drain a blood clot (stereotactic hematoma
aspiration)
insert an endoscope to remove small tumors
and clip aneurysms
Large or complex craniotomies are used to:

remove or treat large brain tumors,

aneurysms, or AVMs
treat the brain following a skull fracture or
injury (e.g., gunshot wound)
remove tumors that invade the bony skull
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include
 increased intracranial pressure
brain edema
 new or recurrent bleeding
infection and
seizure
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a
››a ›a
ü. It is hematoma between inner
periosteum of cranium and duramater.
2.Mostly due to bleed from artery
especially middle meningeal.
3. Commonly associated with
laceration & fracture of overlying
cranial vault.
4.On CT: seen as biconvex
hyperdense area pushing the brain
tissue away.
››a ›a
ü. It occurs between the dura matter,
which adheres to the skull, and the
arachnoid mater enveloping the
brain.
2. due to tearing of bridging veins of
brain.
3. Not always associated with fracture
of cranial bones, may show blunt
trauma.
4. On CT: follows the anatomy of
cerebral hemisphere & is seen
concave away from skull/ crescent
shaped.
|etrograde amnesia?
‡ It is a form of amnesia where one is
unable to recall events that occurred
before the development of the amnesia.
It results from injury to brain regions
associated with declarative memory; the
temporal lobes & especially
hippocamppus.