Subdural Haemorrhage

Question 1

Define subdural haemorrhage (Acute and chronic)

Answer 1

Collection between the dura mater and the surface (arachnoid covering) of the brain

Acute: <3 days old, diffusely hyperdense
Subacute: 3-21 days old, heterogeneously hyperdense/isodense
Chronic: >21 days old, diffusely hypodense

Question 2

What are the causes of subdural haemorrhage

Answer 2

Torsional or shear force causing disruption of bridging cortical veins as they cross the subdural space, emptying into dural venous sinuses
- Non-accidental injury caused by shaking and/or direct trauma in infants and toddlers
- Fall from a considerable height
- Brain shrinkage or overdrainage of hydrocephalus
- Ventriculoperitoneal shunts
- Cerebral aneurysm rupture
- Vascular malformation: arteriovenous malformation or dural fistula
- Rare: cerebral hypotension and malignancy
- Coagulopathy and anticoagulant use

Question 3

What are the symptoms of subdural haemorrhage in younger children

Answer 3

Often discovered after physical examination and imaging
(The history does not provide a plausible mechanism for severity of injury)
- Altered mental status - gradual decrease in GCS, no lucid interval
- Seizures
- Apnoea
- Breathing difficulty
- Sudden cardiopulmonary arrest

Question 4

What are the symptoms of subdural haemorrhage in older children

Answer 4

Headache (Gradual onset, Continuous/constant, worsening after injury)
Raised ICP: nausea and vomiting, early morning headache
Drowsiness
Personality change
Loss of bowel and bladder continence (cerebral dysfunction)
Basilar skull fracture: Otorrhoea, rhinorrhoea

Question 5

What are the features of shaken-baby syndrome

Answer 5

Subdural haemorrhage
Retinal haemorrhages
Encephalitis

Question 6

What are the signs of subdural haemorrhage on examination

Answer 6

Acute: reduced GCS, ipsilateral fixed dilated pupil (midline shift, CNIII compression), bradycardia (brainstem)

Chronic: cognitive impairment, gait deterioration, focal weakness, seizures, focal neurological signs

Question 7

What investigations should be done for subdural haematoma

Answer 7

Bloods: FBC, clotting studies, blood cultures, U&Es, LFTs

Other
- CT head: Crescent shape | Acute: HYPERdense → isodense over 1-3 weeks | Chronic: HYPOdense (similar to CSF)
- MRI brain
- Plain skull x-ray
- Skeletal survey (Suspicion of NAI): rib fractures, skull fractures, long bone and metaphyseal fractures

Question 8

What is the management for subdural haemorrhage

Answer 8

1. Admit and Contact neurosurgeons
2. Advise bed rest
3. Analgesia: paracetamol, codeine, tramadol, morphine, oxycodone (Avoid aspirin and NSAIDs)
4. Stool softener and anti-emetic
5. Maintain normovolaemia and avoid hypovolaemia
6. Compression stockings and intermittent compression

<10mm: observe, mointor
>10mm/midline shift: Burr hole or craniotomy

Question 9

What are the complications for subdural haemorrhage

Answer 9

Neurological deficits e.g. raised ICP, cerebral oedema
Coma
Stroke
Epilepsy
Recurrence of subdural haematoma post-op (33%)
Neuropsychiatric problems: cognitive impairment e.g. mood, memory
Macrocephalus
Chronic hydrocephalus
Neck injury → Spinal cord injury
- More common in high impact trauma e.g. high-speed road traffic collisions
- Most common neck injury: fracture of the upper two cervical vertebrae
Spinal cord injury without bony damage (SCIWORA)

Question 10

What is the prognosis for subdural haemorrhage

Answer 10

Children with severe traumatic brain injury can make a good physical recovery, though the period of rehabilitation may be long
Shaken baby syndrome: 12-30% of victims die and 60-70% suffer from neurological handicap

Question 11

What is the management for shaken baby syndrome

Answer 11

1. Admit to hospital to keep safe
2. Contact child safeguarding immediately
3. Involve seniors
4. Strategy / safeguarding meeting to discuss