The Egyptian Journal of Hospital Medicine (January 2018) Vol.

70 (9), Page 1508-1510

Emergency Management of Subdural Hematoma

Abdulrahman Mubarak Almutairi1, Hassan Mohammed Barnawi2, Ebtesam Mohammed
Alahmari3, Tahani Saeed Almohayya3, Roaa Fahad Alshabanah3, Huda Hussain Mohammad Radwan4
1- Majmaah University, 2- Taibah University, 3- King Khalid University, 4-Ibn Sina National College
Corresponding author: Abdulrahman Mubarak Almutairi - [email protected] – 0564804048

ABSTRACT
Background: subdural hematoma is extra-cerebral accumulation of blood between the dura matter and the
subarachnoid layer. It is almost always caused by trauma or due to blood thinning therapies and occurs due to
rupture of bridging veins. Acute subdural hematoma is an emergency situation and requires prompt diagnosis
using CT most of the time and management requires surgery as well as reversal of anticoagulants.
Aim of the work: In this review, we aimed to study the etiology of subdural hematoma, explore how to
diagnoses and manage it in the emergency department. Methodology: we conducted this review using a
comprehensive search of MEDLINE, PubMed and EMBASE, from January 1985 to February 2017.
Results: surgery is most important intervention in managing subdural hematomas. Conclusion: subdural
hematoma is an important clinical presentation that needs proper and prompt surgical management and
treatment. Treatment should be as less invasive as possible, with higher efficacy and lower recurrence rates.
No-surgical approaches are still being studied with no proven efficacy for them until now.
Keywords: subdural hematoma, diagnosis in emergency room for subdural hematoma, CT vs. MRI,
management of subdural hematoma.

INTRODUCTION January 1985 to February 2017. The following

Extra-cerebral accumulation of blood (whether search terms were used: subdural hematoma,
liquid or clotted) between the dura matter and the emergency management of subdural hematoma, CT
subarachnoid layer is called subdural hematoma. vs. MRI in diagnosis of subdural hematoma,
This hematoma does not cause expansion of the treatment of subdural hematoma
subarachnoid area. The cause of this hematoma is • Data Extraction
almost always trauma. Hematoma will cause an Two reviewers have independently reviewed the
accumulation that will lead to compression of the studies, abstracted data, and disagreements were
brain and focal neurological manifestations. resolved by consensus. Studies were evaluated for
Moreover, it causes an increase in intracranial quality and a review protocol was followed
pressure (with subsequent sequelae) and can affect throughout.
consciousness [1]. The classification of subdural The study was done after approval of ethical
hematomas depends mainly on the time between the board of Majmaah university.
causing trauma and the onset of clinical signs of
symptoms. Subdural hematomas can be classified as Etiology
the following: [2] Subdural hematomas constitute up to 3% of cases
 Acute subdural hematoma: onset of clinical signs presenting to neurosurgery clinics and are most
and symptoms is within three days following likely due to preceding trauma. Usually, trauma
trauma. causing subdural hematoma is minor,
 Subacute subdural hematoma: onset of clinical signs anteroposterior and is associated with emissary
and symptoms is within 4-21 days following veins rupture. The long term use of antiplatelets and
trauma. anticoagulants has been linked to the occurrence of
 Chronic subdural hematoma: onset of clinical signs subdural hematomas and had been shown to affect
and symptoms is after more than 21 days following manifestations and complications, especially in
trauma. chronic hematomas. Moreover, a study had found
that anti-platelets and anticoagulants may be
METHODOLOGY responsible for the occurrence of spontaneous (also
• Data Sources and Search terms known as non-traumatic) subdural hematoma.
We conducted this review using a comprehensive However, the use of these drugs is still considered a
search of MEDLINE, PubMed and EMBASE, from predisposing factor rather than a causing etiology [1].
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Received: 16/12/2017 DOI: 10.12816/0044676
Accepted: 26/12/2017
 Emergency Management of Subdural Hematoma

DIAGNOSIS TREATMENT
Signs and Symptoms Surgery
Chronic subdural hematoma can be quite Surgery is most important intervention in
challenging to diagnose, especially due to its high managing subdural hematomas. Surgical techniques
incidence among elderly, with the vague have developed a lot in the recent years causing
presentation of only decreased physical activity. better outcomes. Common surgical techniques in the
Additionally, the causing trauma may be forgotten treatment of subdural hematoma included: [6-8]
or neglected, causing many cases of misdiagnosis.  Single burr hole technique (also known as
This makes a thorough history that takes even minor minimal craniotomy), which uses a small hole
trauma into consideration essential. This would not which is smaller than 3 cm, with a closed vacuum
be only the responsibility of the patient, but also drainage system. This technique has a variation
family members. Other than trauma, the presence of where sodium chloride solution (physiologic
focal signs indicating brain damage (mainly motor), serum) is used for irrigation.
significantly decreased physical activity and the  Twist drill trephination technique that also uses a
fluctuation of symptoms, all must raise the closed system for drainage. This technique has a
suspicion of diagnosis of subdural hematoma. Other variant called the two-minimal craniotomy
non-specific findings included headache, elevated technique.
intracranial pressure with its associated signs and/or  Craniotomy with a diameter of more than 3 cm,
drowsiness. The nature of signs and symptoms may which is used a vacuum closed system for
help in the localization of the injury. However, drainage. This technique is mainly used in old
confirmation is still needed [3]. cases characterized by the presence of a chronic
septated hematoma.
Investigations
CT vs. MRI Patients with Anticoagulant Therapy
CT and MRI are the main imaging modalities Patients with anticoagulants therapy presenting
used to diagnose a subdural hematoma, with each with chronic subdural hematoma should be treated
one having its advantages and disadvantages. CT separately. This population is of special importance
imaging is more rapid, more feasible and less due to the continuous increase in chronic oral
expensive that MRI. It can help reach a diagnosis anticoagulants use. A recent research found that the
within a relatively short time and aid for proper risk of developing subdural hematoma can be up to
early management. On the other hand, MRI 40 times more in individuals on anticoagulants than
provides valid more accurate results than CT and individuals who are not. Another Swiss study
can show the injured bones more clearly. It is also reported that up to 40% of patients with chronic
effective when diffuse axonal injuries are suspected, subdural hematoma are on a daily anticoagulants
which cannot be detected in CT or other modalities. regimen [9].
The term diffused axonal injuries describes Anticoagulant treatment does not only raise the
degeneration of the Wallerian axons causing axonal risk of developing a subdural hematoma, but also
disintegration. Diffused axonal injuries occur makes its treatment more complicated, due to
mainly in the white matter of the parasagittal cortex, effects of coagulopathy. Therefore, when patients
the pontomesencephalic junction and the corpus with anticoagulants therapy present with a chronic
callosum [4]. subdural hematoma the following must be
In addition to this, MRI can provide clearer considered: their anticoagulants regimen must be
imaging with exact location and dimensions of the adjusted to prevent the recurrence of hematoma and
hematoma. It can also show the relation of the to make surgery more feasible. Even patients with
hematoma with other near structures and the specific indications if anticoagulants (like severe
presence or absence of a mass effect by the cardiac pathology) should be treated in this case [8].
hematoma. MRI also provides a more useful method Patients with antiplatelet therapy are also
in cases of bilateral and/or isodense hematomas. considered at higher risk of developing hematoma
This more accurate and clear information provided and progressing to complications related to it,
by MRI allows the possibility of a better more although their risk is still lower than patients on
effective surgical approach to correct the defect [5]. anticoagulants. When these patients present with a

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 Abdulrahman Almutairi et al.

chronic subdural hematoma, the first step is to stop present, however, relapse rates are still relatively
the anti-platelets therapy allowing for a proper high and studies on surgical techniques efficacy are
neurosurgical management. After proper not conclusive. Generally, any treatment should be
management is performed, the reintroduction of as less invasive as possible, with higher efficacy and
drugs can be considered with careful considerations lower recurrence rates. Non-surgical approaches are
[9]
. still being studied with no proven efficacy for them
Reversal of Coagulopathy until now.
The reversal of coagulopathy can be essential in
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