Neurosurgery notes/Trauma/Primary head Injury/Subdural haematoma (SDH)/Acute SDH

Acute SDH

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Parent item
Subdural haematoma (SDH)

Aetiology

  • Motor vehicle accidents (More in younger)
  • Falls (more in older)
  • Assaults

Mech

Features
Old
Young
Mech
Relative brain atrophy
Greater energy of impact
Parenchymal injury
Low
High
Source
Torn bridging veins
Arterial bleed (20% to 30% of aSDH cases)

Presentation

  • Stereotypic motor disorders,
  • Impaired oculomotor reflexes,
  • Unilaterally fixed and dilated pupils
    • Due to uncal herniation

Radiology

  • If hyperdense bleed is within 10days
  • Acute subdural hematoma appear isointense to brain mech
    • Hematocrit is < 23
      • May cause an acute subdural to appear isointense to brain.
    • Coagulopathy
  • Arterial bleeds are associated with larger clots near the Sylvian fissure.

Management

Conservative methods

  • Indication (Brain Trauma Foundation guidelines)
    • Neurologically stable
    • Haematoma thickness less than 10 mm
    • Midline shift less than 5 mm
    • No pupillary abnormalities
    • No intracranial hypertension on ICP monitoring
  • Outcome
    • Resolve gradually over weeks
    • Some can form a chronic subdural haematoma
  • Bajsarowicz et al 2015
    • N= 869 patients with acute traumatic SDH
      • 646 (74.3%) were initially treated conservatively
    • Good outcome in 76.7%
    • Only 6.5% eventually required delayed surgery
    • Median delay for surgery was 9.5 days
    • Factors associated with deterioration were as follows:
      • Thicker SDH (p < 0.001)
      • Greater midline shift (p < 0.001)
      • Location at the convexity (p = 0.001)
      • Alcohol abuse (p = 0.0260)
      • History of falls (p = 0.018)
    • There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease

Surgically evacuated

  • Must take into account
    • Individual patient age
      • Older poorer outcome
    • Premorbid state, the length of history and any associated injuries
  • Indication (Brain Trauma Foundation guidelines) for
    • Decompression
      • Regardless of the GCS with the following
        • Thickness > 10mm on CT OR
        • Midline shift > 5 mm on CT
      • GCS <9 + SDH < 10-mm thick + midline shift < 5mm
        • Should undergo surgical evacuation of the lesion if
          • GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or
          • The patient presents with asymmetric or fixed and dilated pupils and/or
          • The ICP exceeds 20 mm Hg.
    • For ICP monitoring
      • All patients with acute SDH in coma (GCS < 9)
  • Timing
    • In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible.
  • Methods
    • If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
  • To craniectomy or not
    • RESCUE-ASDH
      • Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group
      • No difference in outcomes for both approaches
          • notion image
      • Interpretation if can replace bone flap I.e. brain not swollen pls replace it
    • Primary decompressive craniectomy is based
      • Degree of intraoperative swelling at the time of surgery.
        • Most important
      • On the injury burden on the brain (e.g. the presence of large contusions)
      • Severity of injury assessed clinically and
      • Mechanism of injury

Outcome

  • Postoperative complications
    • Reaccumulation of the haematoma
    • Infection at the accessed site (e.g. osteomyelitis, meningitis, ventriculitis).
  • High reported mortality rates of 22% to 66%.
  • Prognosis depends on
    • Time to surgery: within four hours to reduce the risk of disability
      • Seelig et al., 1981 Historically
        • Decompression <4 hrs 30% mortality rate
        • Decompression >4 hrs: 90% Mortality rate
      • Bajsarowicz et al., 2015 delay surgery vs no surgery Current
        • No surgery: 8% mortality rate
        • Delayed surgery (median9.5 days): 10% mortality rate
    • Extent of neurologic deficit
    • Sex
    • Postoperative ICP