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General Surgery: Subdural hematoma

Patient will present as → a 74-year-old female who is being treated for mild hypertension. She is found at home with right hemiparesis and brought to the emergency department. Her daughter states that the patient fell in her kitchen 2 days ago, but had no complaints at that time. She did state that her mother sounded a little confused this morning. The patient's left pupil is dilated. CT shows crescent shaped, concave hyperdensity.

Subdural hematoma is usually caused by a head injury, such as from a fall, motor vehicle collision, or an assault. The sudden blow to the head tears blood vessels that run along the surface of the brain.

  • Likely scenario is an elderly patient with a history of multiple falls who is now presenting with neurological symptoms – indicative of a chronic subdural hematoma.
  • Subdural hematomas usually result from injuries to bridging veins.
    1. Acute: symptoms within 48 hours of injury.
    2. Subacute: symptoms within 3 to 14 days.
    3. Chronic: symptoms after 2 weeks or longer - common in alcoholics and elderly patients.
  • Subdural hematoma can occur after an apparently minor trauma and is associated with mental status changes or focal neurologic signs.

CT is diagnostic; once the diagnosis has been established, burr holes over the hematoma are indicated to evacuate the clot.

  • CT shows crescent shaped, concave hyperdensity that can extend across suture line
CT shows crescent shaped, concave hyperdensity

CT shows crescent shaped, concave hyperdensity

Treatment of subdural hematomas depends on their severity. Treatment can range from watchful waiting to surgery.

  • In small subdural hematomas with mild symptoms - no specific treatment other than observation. Repeated head imaging tests are often performed to monitor whether the subdural hematoma is improving.
  • More severe subdural hematomas require surgery to reduce the pressure on the brain. Surgeons can use various techniques to treat subdural hematomas:
    • Burr hole trephination. A hole is drilled in the skull over the area of the subdural hematoma, and the blood is suctioned out through the hole.
    • Craniotomy. A larger section of the skull is removed, to allow better access to the subdural hematoma and reduce pressure. The removed skull is replaced shortly after the procedure.
    • Craniectomy. A section of the skull is removed for an extended period of time, to allow the injured brain to expand and swell without permanent damage (rarely used).

Adapted from surgical recall, by Lorne Blackbourne

osmosis Osmosis
Subdural hematoma


Subdural Hematoma: This is an acute or chronic condition due to venous bleeding that builds up between the dura mater and the arachnoid layer. It often occurs in acceleration-deceleration whiplash injuries and may present days to weeks after the initial injury.

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Question 1
Which of the following patient profiles would be most likely to present with a chronic subdural hematoma?
12-year-old male gymnast with hemophilia A
20-year-old male suffering a head injury 2 hours ago
36-year-old female with head injury 30 minutes ago
55-year-old female with a cerebral aneurysm
78-year-old male with long-standing alcoholism
Question 1 Explanation: 
An elderly patient with long-standing alcoholism is most likely to present with a chronic, asymptomatic subdural hematoma. These patients typically have brain atrophy and more fragile veins that are more likely to tear.
Question 2
A 69-year-old patient is brought into the emergency department with complaints of a headache. He states that he fell down about one hour prior and hit his head on the floor. He was unconscious for a few minutes, according to his daughter, but still has a severe headache. Of note, he feels extremely nauseous. His daughter states that the patient takes warfarin for a heart problem. On exam, his vitals are normal. He has no focal neurological deficits, but appears confused when responding to your questions. His CT scan is shown here. What is the most likely the reason for this patient's complaints.
Subarachnoid hemorrhage
Subarachnoid hemorrhage typically occurs due to ruptured berry aneurysms and presents with the "worst headache" of a person's life. It does not present as crescent shaped on CT scan.
Subdural hematoma
Epidural hematoma
Epidural hematomas may occur due to a laceration of the middle meningeal artery, and typically present with with a patient that had a lucid interval and suddenly looses consciousness. It also presents as biconvex on CT exam
Subgaleal hematoma
Subgaleal hematomas typically present in neonates due to birth trauma, and present with subaponeurotic bleeding that crosses suture lines.
Caput succedaneum
Caput succedaneum also typically present in neonates due to birth trauma with subcutaneous hemorrhage that crosses the suture lines.
Question 2 Explanation: 
An elderly patient with traumatic injury to the cranium with a crescent shaped hyperintense region on CT scan is most likely suffering from a subdural hematoma. He should be treated with therapies such as hyperventilation, diuretics, and fluid restriction to reduce intracranial pressure (ICP). Subdural hematomas are particularly common in the elderly population (whether acute or chronic) due to the decrease in brain parenchymal volume creating a risk of tearing of the bridging veins. Patients with trauma and anticoagulation (especially vitamin K antagonists such as warfarin) are at a much higher risk than their counterparts. Typically, subdural hematomas present with a crescent shaped hyperintensity (blood) on CT scan and present with neurological symptoms such as fatigue, nausea, dizziness, confusion, and seizures.
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