Subdural Hematoma

Also known as Subdural Hemorrhage

A subdural hematoma involves a collection of bleeding lying on the surface of the brain. It usually the result of having a severe head injury, such as with a fall, a motor vehicle accident or a sports injury. If the subdural hematoma is acute, it can be very dangerous-even deadly. The bleeding rapidly fills the spaces in the skull and around the brain, increasing the pressure in the brain and causing death from herniation of the brain. The brain is frequently injured with occasional permanent results.

In the elderly, subdural hematomas can occur after a minor fall or other injury. They can be subacute or chronic and can lead to changes in gait and personality. The elderly person may develop dementia-like symptoms that are written off to old age. Only through thorough testing can the diagnosis of chronic subdural hemorrhage be made.

The cause of a subdural hematoma is the bleeding of the small blood vessels that connect the brain to the overlying covering or dura. The vessels stretch and tear after an injury so that blood collects within the space. In the elderly, the veins are already stretched because the individual has an atrophied brain that is shrunken into the space between the brain and the dura mater.

Sometimes a subdural hematoma happens in the absence of an injury. This can occur when the person is on anticoagulant therapy due to other reasons, is a long term drinker, suffers from recurrent falls (such as in an alcoholic), has repeated head injury (such as a football player) or someone who is very young or very old.

The symptoms of a subdural hematoma include confusion, speech abnormalities, balance or walking difficulties, severe headache, loss of consciousness, lethargy, vomiting and nausea, seizures, numbness of a part of the body, weakness, visual changes, or slurring of speech.

If a subdural hematoma occurs in an infant, the symptoms can be different and can include the presence of a bulging fontanelle, which is one of the soft spots of the skull. There can be focal seizures and difficulty feeding. The cry can be high pitched and there can be a sudden increase in head circumference. Generalized seizures are also possible and the baby may seem to be lethargic. There is persistent vomiting, irritability and separation of the sutures of the skull.

Doctors need a relatively quick diagnosis of a subdural hematoma, especially if the situation represents an acute subarachnoid bleed. There should be a complete physical and neurological exam. Sometimes bruising can be seen in the area of trauma. The doctor might find confusion in the speech or an inability to speak; there can be problems with walking or balance; a headache can be asked about; there can be loss of consciousness or lethargy. The doctor may find localized numbness of a body area as well as nausea and vomiting. In an elderly person, there can be a sudden or relatively sudden loss of cognition.

Other tests that can be done include a CT scan or MRI scan of the brain, which can show up areas of bleeding in a subdural hematoma. It can also show the degree of pressure on the brain.

The treatment of subdural hemorrhage includes emergency craniotomy to take extra bleeding and pressure off the brain. It may be enough to drill a small hole on the side of the subdural hematoma so that the blood can flow outward. Mannitol is used to control swelling on the brain and medications for seizures and pain need to be given. If the person is unconscious, there may be a need for ventilator support. Blood pressure needs to be decreased so that the flow of blood through the brain is under less pressure. Corticosteroids are used to decrease the pressure and inflammation on the brain.