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Save of the Month: Subdural Hematoma with Midline Shift

Dr. Berland was in Fast Track getting peppered with Shetty trivia when a middle-aged man came in complaining of headache and pain in his right leg after having what appeared to be minor trauma a week before. He had stood up while cleaning a chimney and hit his head on the ceiling above him. He denied LOC, nausea, vomiting and was not on blood thinners. He reportedly looked great and could easily have been discharged with acetaminophen, but Noah picked up a subtle weakness of his right leg.

He immediately ordered a head and c-spine CT, and worked hard to quickly get the patient to the scanner. The CT showed a massive subacute subdural hematoma with 11 mm midline shift. Neurosurgery…

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Articles of Interest

Emergency Management of Subdural Hematoma

Subdural hematoma is an important clinical presentation that needs proper and prompt surgical management and treatment. Treatment should be as less invasive as possible, with higher efficacy and lower recurrence rates. No-surgical approaches are still being studied with no proven efficacy for them until now.

External drains versus no drains after burr‐hole evacuation for the treatment of chronic subdural haematoma in adults

There is some evidence that postoperative drainage is effective in reducing the symptomatic recurrence of CSDH. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Not Just a Knock to the Head

A traumatic acute subdural hematoma can be a neurosurgical emergency with mortality as high as 60% to 80%. About half of the patients with large acute hematomas survive, though permanent brain damage can occur secondary to the trauma.

Podcast #166: Subdural Hematoma

Any SDH greater than 5mm is considered for surgical intervention if the patient is symptomatic, and any SDH greater than 10mm or with significant midline shift, regardless of symptoms are surgically treated.

Prognosis of acute subdural hematoma greater than 10 mm in thickness

This study emphasized that both surgical and conservative management of ASDH had similar dismal results and that there was no additional benefit from surgical intervention in the studied group of head injury patients. Randomized controlled trials are needed to set a standard of care for the management of ASDH in this subgroup of the severe head injury patients.

Subdural hemorrhage

Subdural hemorrhage (SDH) (also commonly called a subdural hematoma) is a collection of blood accumulating in the subdural space, the potential space between the dura and arachnoid mater of the meninges around the brain. Subdural hemorrhage can happen in any age group, is mainly due to head trauma and CT scans are usually sufficient to make the diagnosis. Prognosis varies widely depending on the size and chronicity of the hemorrhage.

The True Cost of Chronic Subdural Hematoma

The researchers conclude that Burr hole washout is superior for both patients’ clinical and financial outcome. They acknowledge that prospective long-term multicenter clinical studies would solidify these findings.

Resources

StatPearls

A subdural hematoma is not a benign disorder; mortality rates of 30% to 80% have been reported. Even those who survive may never fully regain functioning. Good outcomes are seen in less than one-third of patients. Younger patients tend to have better outcomes compared to older individuals.