Chronic SDH.pptx............................

CHRONIC SUBDURAL HEMATOMA
DR. BHAWANI SHANKER SHARMA
PROF. & HEAD, NEUROSURGERY
DIRECTOR, NEUROSCIENCES
Mahatma Gandhi Medical College, JAIPUR

●Encapsulated collection of
old liquefied blood
between dura and
arachnoid.
●Virchow (1857)-
Pachymeningitis
Haemorrhagica Interna
Definition

Acute Chronic
●Young adult
●Major trauma
●Immediately after H1
●Structural brain injury
●Solid
●Bad - prognosis depends
on extent of injury
●Elderly
●Trivial trauma in 50%
cases
●Delayed presentation { 1
month}
●None
●Liquid
●Excellent

●Incidence- 18/ lakh
●Incidence increases to
58/lakh in > 65 years
(disease of elderly)
●2-3% in NS clinic
●Bilateral in 20-25%
cases
Incidence

●Fall
●Anticoagulants/ antiplatelet drugs
●Bleeding diatheses
●Hemodialysis
●Alcohol
●Epilepsy
Etiology and Risk factors

●Advancing age
●Alzheimer and brain atrophy
●Dehydration
●Low intracranial pressure
➢ Lumbar puncture and spinal surgery
➢ Post lumbar puncture headache (>1 week)
➢ Post partum headache (epidural anaesthesia)
➢ Microdiscectomy, complicated by CSF leak
➢ VP shunt, ETV
Risk factors cont…

Increased space between brain and skull from 6% to 11%
Ac SDH
Ageing
Lack of tamponading effect atrophied brain
A-P : movement of skull stops but brain continues due to inertia (acc/
decl) – stretching and ruptures bridging veins – small acute SDH
Generalised cerebral atrophy
Pathogenesis

3 weeks-Thin membrane
Liquefaction
Spontaneously absorbed Slowly increases
Thin film of fibrin and fibroblast
Pathogenesis

1. Osmotic theory- increased protein content and oncotic
pressure
- liquefaction of hematoma
- neocapillaries
- vascular hyperpermeability
- increase fibrinolysis
2. Recurrent micro bleeding-presence of abnormal dilated
vessels in the capsule and increase fibrinolytic activity
within capsule - most accepted
3. Nature of fluid- watery, altered blood and fresh blood
clot depending upon the age of the CSDH & recurrent
bleeding
Pathogenesis

● Increase venous fragility
● Increased inflammatory marker in Chronic SDH fluid
● Interleukin
● Angiogenetic growth factor
● Vascular endothelium growth factor
● Fibroblast growth factor
Pathogenesis

●Behavior disorders
●Mental deterioration
●Altered mental state
●Confusion, drowsiness, coma
1. Psychiatric symptoms
Clinical Symptomatology

●Insidious onset, gradually progressive
●Increased ICP – Headache, vomiting
2. Tumor synd

●Memory dist/ dementia
●Incontinence
●Gait dist
3. NPH

●Hemiparesis
●Paraparesis
●Hemisensory deficit
●Speech difficulty
●Quadriparesis
4. Focal deficits

• Parkinson’s synd
• Choreoathetoid
• Akinetic rigidity
5. Extrapyramidal synd

●Vertigo
●Fatigue
●Recurrent falls
●Headache – persistent, non-postural
6. General symptoms

●Seizures
●Occulomotor palsy
●Blephrospasm
●Nystagmus
7. Isolated neurological symptoms/ signs

●Ease of falling
●TIA
Rare presentation

●General physicaian/ Neurologist/ Neurosurgeon has to
be aware of existence of chronic SDH in elderly
patient on anticoagulant/ antiplatellete/ trivial trauma
●High index of suspicion

●Recurrent fall/ asprin
●Headache- persistent and non postural
●Seizure – simple partial seizure
●TIA
Suspect -

●Tumour
●SAH
●Stroke/ CVA
●NPH
D/D

●Contrast inhanced CT- investigation of choice – easily
available, quick
●Repeated microhemorrhage- hetergenous or
hyperdense because of different age of hematoma
- Acute phase-hyperdense – within 3 days
- Subacute- isodense – 4-21 days
- Chronic- hypodense – after 21 days
Diagnosis

●Isodense hematoma difficult to visualise
●Indirect finding-
1. Convex border appear flattened or
concave
2. Effacement of the sulci
3. Compression of the ipsilateral
ventricle
4. Bilateral- squeezed ventricle or
rabbit ear
5. Obliteration of basal cistern
CT Scan

●Homogenous
●Trabecular
●Septated
●Laminar- ESR effect
Nakaguchi classification – types
Recurrence low
Recurrence high

1. Isodense uni or bilateral lesion
2. Multiloculated
3. In recurrence to see size of capsule
Indications
MRI

●May resolve spontaneously – idiopathic
thrombocytopenia
Management

1. Conservative or medical
− asymptomatic small hematoma
− high risk patient
‣ antiepileptic
‣ ACE inhibitor
− Careful monitoring with RPT CT
− Only by neurosurgeon
Management

− etizolam (platelet activating factor receptor
antagonist) promotes chronic SDH resolution
− Oral Tranexamic Acid – 75mg/day
− Steroid - oral steroids for 2 months – starting 60mg
OD & gradually tapering
− No convincing evidence so not recommended

2. Surgery –
− Bed side twist drill in sick patients
− Burr hole
− Mini craniotomy
Urgent reversal of anticoagulation with FFP,
prothrombin complex concentrate (PCC) or RF VIIa,
VitK

●Local or general anaesthesia
●Two or one burr hole
●One time drainage method or continuous drainage
Burr hole

●Reserved for
1. Multiple Recurrence and Re-accumulation
2. Solid hematoma
3. Multiple membrane
4. Thick membrane
5. Multiloculated
6. Organized
7. Calcified/ ossified
Craniotomy

●Head end low, foot end elevated 48-72 hours adequate
hydration > 2000ml/day
●Early mobilization after surgery (3 days)
can prevent- atelectasis
- pneumonia
- decubitus ulcer
- DVT
- UTI
● Restarting of antiplatelet and anticoagulant after 72
hrs but individualized
Postoperative care

●Re-accumulation- most common
●Only symptomatic collection is labeled – recurrence
- 5-33% incidence
- within 3 month( early recurrence)
Complication
Asymptomatic
Symptomatic

● Bleeding tendency
● Intracranial hypotension
● Diabetes
● Pre operative seizure
● Low GCS
Predictor of recurrence – Clinical

●high or mixed density appearance on CT
●> 20 mm width of hematoma
●Post op midline shift > 5 mm
●Laminar/ multilayered hematoma
●Thick membrane, Neomembrane
Predictor of recurrence – Radiol

●Inadequate evacuation of hematoma
●Brain remaining in the depth at end of surgery/
inadequate expansion of brain
●Presence of air 7 days after surgery
Predictor of recurrence – Post op

●Close continuous drainage for 3 days in >60 years
●Post op hydration (at least 2.5 litres/ day)
●Prevention of pneumocephalus
●Irrigation with large amount of fluid during surgery
●Use of gravity to help brain re expansion
Method to reduce recurrence

●Focal brain injury
●Post operative acute subdural hematoma
●Seizure- prophylactic anticonvulsant for 6
month
●Tension Pneumocephalus
●Surgical site infection
●Subdural empyema
Non surgical non specific complication – MI,
DVT, pneumonia
Mortality – 2%
Specific surgical complications –

●Suspect Chronic SDH in elderly patients specially H/O
minor trauma/ fall at home/ asprin therapy
●Dynamic lesion – symptoms may be fluctuating
●CT – investigation of choice
●Surgery is simple and results are excellent
Take home message

●Prognostic factor- neurological status GCS at time of
diagnosis
●Timely diagnosis, referral and treatment is important
Prognosis

Chronic SDH.pptx............................

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