Acute Subdural Hematoma
Acute Subdural Hematoma
Acute Subdural Hematoma
Acute subdural hematoma are one of the leading causes of death disability in
patient with severe traumatic brain injury. Subdural hematomas (SDHs) are
much more common than epidural hematomas (EDHs) most do not a cures as
isolated injuries the vast majority of SDHs are associated with traumatic
subarachnoid hemorrage as well as significant parenchimal injuries such as
cortical countusions, brain lacerations, and diffuse axonal injuries.
Terminology
Etiology
Trauma is the most common cause of aSDH. Both direct blows to the head and
non-impact injuries may result in formation of an aSDH. Tearing of bridging
cortical veins as they cross the subdural space to enter a dural venous sinus
(usually the superior sagittal sinus) is the most common etiology. Cortical vein
lacerations can occur with either a skull fracture of the sudden changes in
velocity and brain rotation that occur during non-ampact closed head injury.
Blood from ruptured vessels spreads quickly through the potential space
between the dura and the arachnoid. Large SDHs may spread over an entire
hemisphere, extending into the interhemispheric fissure and along the
tentorium.
Tearing of cortical arteries from a skull fracture may also give rise to an
aSDH.The arachnoid itself may also tear, ceating a pathway fo leakage of CSF
into the subdural space, resulting in admixture of both blood and CSF.
Pathology
Demographics. An aSDH may occur at any age from infancy to the elderly.
There is no gender predilation.
Clinical findings very from none to loss off consciousness and coma. Most
patient with aSDHs have low Glascow Coma Scores an admission. Delayed
deterioration, especially in elderly anticoagulated patients, is common.
Both standard soft tissue and intermerdiate (‘subdural’) windows should be used
in all trauma patients as small, subtle aSDH can be obscured by the density of
the overlying calvaria.
CT Findings
NECT. Approximately 60% of SDHs are hyperdense on NECT scans (2-25), (2-
26). Mixed attenuation lesions are found in 40% of cases. Pockets of
hypodensity within the larger hyperdense collection (‘swirl’ sign) usually
indicate rapid bleeding ‘Dots’ or ‘Lines’ of CSF trapped within compressed,
displaced sulci are often seen underlying an aSDH (2-27).
Mass effect with an aSDH is common, in some patients, especially athletes with
repeated head injury, brain swelling with unilateral hemisphere vascular
engorgement occurs. Here the mass effect is disproportionate to the size of the
SDH, which may be relatively small. This entity, the ‘second impact syndrome’
is probably caused by vascular dysautoregulation (see chapter 3).
CECT. CECT seans are helpful in detecting small isodense aSDHs. The
normally enhancing cortical veins are displaced inward by the extraaxial fluid
collection.
DWI shows heterogeneous signal within the hematoma but may show patchy
foci of restricted diffusion in the cortex underlying the aSDH.
Differential Diagnosis