Subdural heamatoma (acute/chronic)

Question 1

common symptoms someone may present with

Answer 1

left sided weakness, headache and a history of fluctuating consciousness , frequent falls

Question 2

on obtaining a further history, what would you like to ask?

Answer 2

SOCRATES, systemic symptoms, enquire about other neurological symptoms indicative of raised ICP: = visual problems, nausea, vomiting, focal neurology, loss of consciousness, seizures, PMH, fever/infection signs

Question 3

The patient describers their headache as dull and constant and is not relieved by paracetamol , no vision loss- what further investigations may you do?

Answer 3

GCS, comp neuro examination + cranial nerves and pupillary response. FBC’S, U+E’s, LFT’S, B12 level, glucose, clotting profile (INR)

Question 4

What is the best method of scanning for intra cranial bleeding to help exclude neoplasm and stroke?

Answer 4

CT scans

Question 5

How can you tell the difference between an acute and chronic SDH?

Answer 5

appearance varies with clot age

acute - haematoma is hyperdense (white)

Question 6

Why does the colour of the clot change with age

Answer 6

protein degeneration causes the density to drop

Question 7

A chronic SDH will become more?

Answer 7

isodense to the adjacent cortex - identification is therefore tricky

Question 8

the typical shape of a subdural haematoma on neuroimaging? why is this

Answer 8

crescenteric , the subdural space is not restricted to the skull suture lines

Question 9

What actually is an SDH

Answer 9

collection of blood accumulating in the subdural space

Question 10

where is the subdural space

Answer 10

between the dura and arachnoid matter

Question 11

what are the 3 meningeal layers, what order do they lie?

Answer 11

dura, arachnoid and pia (outer to inner)

Question 12

What vessels are damaged in SDH’S?

how are they damaged?

Answer 12

stretching and tearing of bridging cortical veins as they cross the subdural space to drain into an adjacent dural sinus

Question 13

chronic SDH are more common in?

Answer 13

elderly patients or chronic alcohol abuse patients

Question 14

why is chronic SDH more common in elderly and chronic alcoholics ? this means it can occur after only?

Answer 14

cerebral atrophy- this causes increased tension on the bridging veins which predisposes them to tears, minor head injuries

Question 15

following a SDH, what occurs?

Answer 15

local inflammatory response - heamatoma cavity forms in the membranes - clot liquifies and haematoma expands

Question 16

Acute SDH are most common a cause of

Answer 16

traumatic brain injury - blunt trauma or decelerations or rotational injury

Question 17

with acute SDH, patients may be?

Answer 17

in a coma from the onset

Question 18

risk factors for chronic SDH’S?

Answer 18

> age , cerebral atrophy, anti-platelet/ anti-coagulation drugs, frequent falls, head trauma, haemodialysis, alcohol

Question 19

How do CHRONIC SDH’s typically present ?

Answer 19

variable - progressive drowsiness, confusion, headache, personality changes, depression or neurocognitive dysfunction

Question 20

What focal neurological deficits may be present in Chronic SDH?

Answer 20

hemiparesis, dysphasia

Question 21

20% of chronic SDH cases are ?

Answer 21

bilateral - localisation of neurological deficits may be difficult

Question 22

How can you differentiate acute vs chronic in terms of presentation

Answer 22

acute- rapid progression of symptoms, often obtunded from the moment of injury

Question 23

in acute SDH, large elevations of ICP may lead to ?

Answer 23

uncal herniation/tonsillar herniation and cushing’s reflex

Question 24

Chronic SDH management

Answer 24

neurosurgery for assessment, non-surgical (serial CT scans, outpatient basis) and surgical treatment (burr holes, craniotomy and evacuation of the clot)

Question 25

in chronic SDH’s , how are asymptomatic patients normally treated, when is a surgical evacuation considered?

Answer 25

treated conservatively

neurological deficit, thickness of haematoma >19mm, midline shift >5mm or progressive increase on serial imaging

Question 26

what is also important to remember in chronic SDH management

Answer 26

reverse any coagulopathies including iatrogenic anti-coagulation

Question 27

a sub-galeal drain may be put in after burr hole surgery - what is the purpose of this?

Answer 27

assists in the evacuation of the haematoma and air and reduces the risk of cSDH reoccurrence and pneumocephalus

Question 28

Potential complications of surgical treatment?

Answer 28

infection, seizures, intra-cerebral haemorrhage, subdural empyema

Question 29

what does subdural air have a mass-effect over? what is the re accumulation rate?

Answer 29

underlying brainparechyma , 30%

Question 30

what is indicative of tension pneumocephalus

Answer 30

mount fuji sign (gas in tips of the frontal lobes)