Subdural Hematoma: Know the Facts Before You Panic
Subdural hematomas (SDH) are bleeding between the surface of the brain and its covering membrane called the meninges. These hematomas can occur in many different circumstances including head trauma, certain types of medical conditions, and even some surgical procedures. In fact, they’re actually quite common. However, SDHs can vary widely in size and location. Some patients have a small red spot on their scalp, while others may experience a severe headache, nausea, vomiting, confusion, or loss of consciousness.
- After having an acute subdural hematoma, 20 to 30% of patients regain full or partial brain function.
- There is a 50 to 90 percent mortality rate associated with acute subdural hematomas.
There are two types of SDH: acute and chronic. Acute SDH occurs suddenly and is often caused by trauma. Chronic SDH may occur gradually over time due to repeated minor head injuries. Both forms of SDH have similar symptoms and treatments.
Point to note: Some people think that these lesions are harmless – after all, they don’t cause any symptoms at all. However, this isn’t always true. A significant number of patients develop neurological issues following an SDH, ranging from mild temporary changes in mental status to full-blown strokes. It’s estimated that around 20% of cases involving SDHs result in permanent neurologic disability.
How do I know if my child has a Subdural Hematoma?
Children who present to the Emergency Department (ED) with a history of head injury should receive a CT scan of their head. If they show any sign of increased intracranial pressure, then further imaging studies should be performed. A CT scan can detect an SDH if it is present. However, the test cannot tell whether a patient has an SDH. Therefore, children who have no clinical findings suggestive of SDH should not undergo CT scanning unless it is medically necessary.
What causes SDHs?
In order to understand what causes SDHs, we first need to know a bit about how blood flows through our bodies. When blood leaks out of an artery and travels through a vein, it forms two streams of liquid. One stream moves away from the leaking vessel and enters a capillary; the other stays inside the capillary waiting until someone notices that something went wrong.
The cause of SDH is not fully understood, however, some factors have been identified as contributing to the condition. These include head trauma, high-impact sports injuries, certain medications, coagulopathies, and vascular abnormalities. In addition to these risk factors, SDH may occur spontaneously without any known precipitating event. In fact, many patients who present with SDH do not report any history of trauma.
Diagnosis
To diagnose an SDH, doctors use CT scans and MRI scans, both of which provide detailed information about the patient’s internal structure. Unfortunately, neither technology provides a definitive diagnosis. Even though these tests show whether there is a mass of blood within the skull, they do not confirm whether the mass is caused by a bleed or whether it was already present before the accident occurred.
Typically, the best way to determine whether a stroke has occurred is to perform a lumbar puncture. Doctors insert a needle into the lower spine to obtain spinal fluid for testing. The spinal fluid contains proteins, glucose, creatinine, and other substances that help doctors identify potential abnormalities. For example, if the protein levels are abnormally high, it may indicate an infection or inflammation, whereas low protein content indicates dehydration.
Although lumbar punctures are relatively effective tools for diagnosing SDHs, the procedure is somewhat invasive and carries the risk of infection and hemorrhage.
Symptoms of Subdural Hematoma
The first symptom of an SDH is a headache. Headaches may be severe or mild depending on how much blood is present in the brain. Other symptoms include nausea, vomiting, dizziness, confusion, seizures, loss of consciousness, vision changes, and paralysis. If left untreated, SDH can cause permanent damage to the brain.
Some more symptoms of subdural hematoma are as below:
- Headache
- Nausea
- Vomiting
- Difficulty speaking
- Seizures
- Confusion
- Dizziness
- Loss of consciousness
- Weakness
- Blurred vision
- Fatigue
- Sudden loss of memory
What Are Treatments?
The treatment of subdural hematoma is mainly surgical. Removal of the blood clot is done either under general anesthesia or local anesthesia. Surgical removal of the blood clot is also called a craniotomy. Generally, patients recover well without any complications following surgery. However, complications do occur occasionally. These complications require further procedures and/or medications to improve the outcome for the patient.
There are certain drugs that are commonly prescribed to treat SDH. They include fibrinolytic agents (e.g. alteplase), steroids (e.g. dexamethasone), and mannitol. Mannitol helps to reduce intracranial hypertension in case of raised ICP. Fibrinolytics work by lysing blood clots and reducing intracranial pressure. Steroids work by diminishing inflammation caused by the accumulation of blood cells resulting in decreased intracranial pressures.
The most common treatments for SDH involve removing the blood clot, draining the excess liquid around the brain, and preventing further bleeding. Depending on the severity of the injury, doctors may use different methods to remove the blood clots.
- Surgery: In some cases, surgery is necessary to remove the blood clot. Surgery involves opening the skin over the affected area and using instruments to carefully cut away the damaged tissue. Afterward, doctors drain any remaining blood from the brain and close the wound. If the damage is extensive, surgeons may need to place a shunt inside the brain to help prevent future bleeding.
- Craniotomy: If the patient does not have significant brain swelling, doctors may perform a craniotomy instead of surgery. Craniotomy means cutting open the scalp and cranium to access the injured brain tissue. Doctors then drain the excess blood and remove the clot.
- Medical Management: For patients who do not require surgical intervention, doctors often prescribe medications to reduce the risk of further bleeding. These drugs work by decreasing the amount of blood flowing to the brain, thereby reducing swelling. Commonly prescribed drugs include mannitol, cortisone, aspirin, and anti-platelet agents.
Prevention
There are several ways to prevent SDH. First, avoid activities that involve sudden acceleration or deceleration. These activities include riding motorcycles, skateboarding, snowmobiling, skiing, horseback riding, rollerblading, bicycling, and car racing. Second, wear helmets while participating in sports or playing contact sports. Third, do not drink alcohol before driving or operating heavy machinery. Fourth, get regular checkups with your doctor to make sure you don’t have any underlying conditions that could lead to an SDH.
The bottom line,
The first step in treating a Subdural Hematoma is to remove any foreign objects that may have caused the injury. Once the object(s) have been removed, doctors will monitor the patient’s condition closely. Depending on how severe the injury is, patients may need surgery to drain the fluid buildup. Afterward, they may receive medication to reduce inflammation and prevent further bleeding.
Some people who suffer from SDH do not require medical attention at all. However, if you notice symptoms such as headache, nausea, vomiting, slurred speech, confusion, weakness, or vision problems, then you should seek help immediately.
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