Subdural haematoma

Subdural haematoma (SDH) has a variable disease course, depending on size of haematoma, age of the patient, presenting neurological signs/symptoms, presence of underlying coagulopathy or neoplasm, and associated injuries.

One week of prophylactic anticonvulsants (e.g., phenytoin, levetiracetam) should be considered in all cases of acute and acute-on-chronic SDH, according to the Brain Trauma Foundation guidelines.

Tailored management and reversal of antithrombotic therapy is a key element of initial care for all patients with SDH.

The choice between surgery or conservative management for SDH is typically based on haematoma size, extent of midline shift, severity of neurological dysfunction and degree of raised intracranial pressure (ICP). The degree of surgical risk and potential for recovery may also be considered.

Observation may be employed for small, stable SDHs that are not causing neurological compromise.

Control of raised ICP using head-of-bed elevation, analgesics, intubation with anaesthetics and sedation, hyperosmolar treatment, barbiturates, or decompressive hemicraniectomy may be required.

Treatment complications include early or delayed re-accumulation of SDH, seizures, vascular injury to cortical veins and arteries or dural sinuses adjacent to the haematoma, strokes, persistent neurological deficit, coma, and death.

SDH is a collection of blood between the dural and arachnoid coverings of the brain. As the volume of the haematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation. While the presence of SDH can be inferred by neurological decline and mechanism of traumatic injury, the diagnosis is typically made radiographically (computed tomography or magnetic resonance imaging).