Neuroimaging Mastery Project: Presentation #5 Subdural Hematomas

Subdural Hematomas
Madison Watts, MD1, Rebecca DeCarlo, MD2,
Faith Meyers, MD1, Steven Perry, MD1
Carolinas Medical Center & Levine Children’s Hospital
Department of Emergency Medicine1
Charlotte Neurosurgery & Spine Associates2
Michael Gibbs, MD, Imaging Mastery Project Lead Editor
Neuroimaging Mastery Project
Presentation #5

Disclosures
▪ This ongoing series is proudly sponsored by the Emergency Medicine and
Neurosurgery Residency Programs at Carolinas Medical Center.
▪ The goal is to promote widespread mastery of imaging interpretation.
▪ There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

Meet Our Neuroimaging Editorial Team
Andrew Asimos, MD, FACEP
Medical Director, Atrium Health Stroke Network
Neurosciences Institute
Clinical Professor, Department of Emergency Medicine
Jonathan Clemente, MD, FACR
Chief, Department of Radiology, Carolinas Medical Center
Charlotte Radiology, Neuroradiology Section
Adjunct Clinical Associate Professor, Department of Radiology
Andrew Perron, MD, FACEP
Associate Dean of Graduate Medical Education and Designated Institutional Official
Professor of Emergency Medicine
Department of Graduate Medical Education
Dartmouth Hitchcock Medical Center

Meet Our Neuroimaging Editorial Team
Christa Swisher, MD, FNCS, FACNS
Neurocritical Care/Pulmonary Critical Care Consultants
Department of Medicine, Atrium Health
Clinical Assistant Professor, Department of Neurology
Scott Wait, MD, FAANS
Chief, Pediatric Neurosurgery, Levine Children’s Hospital
Carolina Neurosurgery & Spine Associates
Adjunct Clinical Associate Professor, Department of Neurosurgery

Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

Before We Start, Let’s Review A Few Basic
Principles Of CT Neuroimaging Interpretation

0 +40 +80 +1000
-1000 -40
-80
H20
⫽
⫽
Brain
CT Basics: Density
Blood
The Denser The Object, The Whiter It Is On CT
Bone
Air
Hounsfield Units

Acute 1-3 Days Hyperdense (80-100 HU) relative to brain
Subacute 3-14 Days Variable density relative to brain
Chronic >14 Days Hypodense (<40 HU) relative to brain
Hounsfield
Units
Days
Hyperdense
Isodense
Hypodense
100
20
1 14
Neurosurgery Clinics of North America 2017. 28:247-255.
CT Basics: Subdural Hematoma CT Scan Density Decreases Over Time1
1These represent
approximate times.

Acute SDH
0-3 Days Old
Hyperdense On CT
Subacute SDH
3-14 Days Old
Isodense On CT
Chronic SDH
>14 Days Old
Hypodense On CT
CT Basics: Subdural Hematoma CT Scan Density Decreases Over Time1
1These represent approximate times.

The term DENSITY is used when interpreting head CTs in patients with SDH.
ATTENUATION is another term, often used by neuroradiologists, to describe
the same phenomena.

CT Basics: Use Different Windows To Identify The Important Findings
Standard Window Brain Window
In This Case The Same
CT Image Is Shown
With Two Different
Windows
Windowing Alters The
Appearance And Contrast
Between Different
Components Of The Image.
This May Make It Easier For
You To Identify Hemorrhages
That Are Either Subtle Or
Isodense With The Adjacent
Bone Or Brain.
From: www.EMguidewire.com – July 2023.

Always Use A Structured Approach To Head CT Interpretation!
Blood Can Be Very Very Bad
B = Blood
C = Cisterns
B = Brain
V = Ventricles
V = Vessels
B = Bone

Subdural Hematomas (SDH)
Cases From Carolinas Medical Center

Subdural Hematomas (SDH)
• The dura mater adheres to the periosteum
of the skull
• The pia mater adheres to parenchymal
tissue of the brain
• Bleeding into the subdural space bleeding
from a number of sources, often the
bridging veins

Acute SDH
• 75% are traumatic and
25% are atraumatic
• Atraumatic SDH can be
caused either by
spontaneous bleeding into
the subdural space or by
the extension of
intraparenchymal bleeding
Etiologies of Atraumatic SDH
Ruptured intracranial aneurysm
Ruptured cortical artery
Hypertensive intracerebral
hemorrhage
Neoplasm (primary brain,
hematologic and metastases)
Hematologic disorder (most
commonly factor deficiencies)
Anticoagulant use
Thrombolytic therapy
Cerebral amyloid angiopathy
Dural arteriovenous fistula

Case #1
A 63-year-old female presents to the ED with increasing confusion noted by
her neighbor. She had an unwitnessed fall yesterday.
Further History:
• The patient does not drink alcohol
• She is not taking anticoagulants
The Initial Examination Shows That:
• She has stable vital signs and a GCS=15
• She is awake, slow to respond, answering questions appropriately
• She has equal pupils and no focal neurologic deficits
• There is a large contusion to the left side of the face

Standard Window
Brain Window
Head CT Reveals An Acute
Holohemispheric Subdural
Hematoma.
• Thickness
• Midline Shift
9 mm
6 mm
Case #1

Standard Window
Brain Window
Case #1
Hematoma.
• Thickness
• Midline Shift
9 mm
6 mm
The Patient Underwent
Craniotomy And SDH
Evacuation

Standard Window
Case #1
Post-Operative Day #1

Case #2
A 68-year-old female with a history of diabetes found unresponsive on the
bathroom floor.
Further History:
• The patient does not drink alcohol
• She is not taking anticoagulants
• GCS=3 upon ED arrival and she was immediately intubated
• Before intubation she had equal 3 mm sluggish pupils, no spontaneous
movement, and she was not lateralizing.

Hematoma With
Hydrocephalus And Loss Of
Basilar Cisterns.
• Thickness
• Midline Shift
21 mm
16 mm
The Patient Underwent
Craniotomy And SDH
Evacuation
Case #2

Intraoperative Images
The dura has been reflected anteriorly to expose the
brain and there is a large collection of acute subdural
blood. As the clotted blood is being removed the
underlying brain is partially visible.
Post-Operative Head
CT

Acute SDH
• Our patient’s SDH is
hyperdense on CT in
comparison with the
adjacent brain
• This CT appearance is
consistent with an acute
SDH
• This CT findings fit with
the clinical history

Hounsfield
Units
Days
Hyperdense
Isodense
Hypodense
Subdural Hematoma CT Scan Density Decreases Over Time
100
20
1 14
Acute

What Are The Indications For Surgical
Evacuation In Patients With Acute SDH?

Neurosurgery 2006;58:S16-S24.
Surgical Management Of Acute Subdural Hematoma
Indications For Surgery:
• A SDH thickness >10 mm regardless of GCS,
• Midline shift >5 mm regardless of GCS,
• All patients in coma (GCS score less than 9) should undergo ICP monitoring,
• Patients in coma with a SDH <10 mm thick and/or a midline shift <5 mm should
undergo surgical evacuation if:
⮚ The GCS decreased by ≥2 points between the time of injury and hospital admission,
⮚ The patient presents with asymmetric or fixed and dilated pupils,
⮚ Intracranial pressure >20 mmHg.
2006 Guidelines

What Does The Most Recent Literature Tell Us
About The Impact Of The Timing Of Surgery?

Time Interval To Surgery And Outcomes Following The Surgical
Treatment Of Acute Traumatic Subdural Hematoma
Journal of Clinical Neurosciences 2014;21(12):2107-2111.
Objective:
To determine the association between surgical timing and outcomes in patients with subdural hematoma.
Methods:
Single-center retrospective review of 512 TBI patients between 2006-2012. After excluding patients with
penetrating trauma, epidural hematoma, concurrent intraparenchymal injury > 30 mL, 45 patients remained
for the analysis. The primary outcome measure was in-hospital mortality.
Results:
The two predictors of in-hospital mortality were:
• Increased injury severity [OR] 1.146; 95% CI: 1.035–1.270; p = 0.009.
• Increased age [OR] 1.066; 95%CI 1.006–1.129; p = 0.031.
Increased time to surgery was not associated with increased mortality [OR] 0.984; 95%CI 0.971–0.997; p = 0.018.

Reducing Time-to-Treatment Decreases Mortality of Trauma Patients with
Acute Subdural Hematoma
Annals of Surgery 2011;253(6):1178-1183.
Objective:
To determine if reducing prehospital time and time-to-craniotomy is associated with decreased mortality in
trauma patients with acute subdural hematomas.
Methods:
Retrospective study 149 of patients with acute subdural hematomas and without severe torso injuries, who
required craniotomy at a Canadian level 1 trauma center from 1/1996 to 12/2007. The independent
variables were prehospital time and time-to-craniotomy. The primary outcome measure was mortality.
Results:
There was a strong trend suggesting that patients arriving within the “Golden Hour” had decreased
mortality (37% vs. 53%, P = 0.09). Increased prehospital time was found to be associated with increased
mortality (odds ratio 1.03 per minute, 95% CI 1.004–1.05, P = 0.024). However, there was no difference in
mortality for patients undergoing craniotomy within 4 hours and after 4 hours (42% vs. 36%, P = 0.4).

When Surgical Evacuation Is Indicated, Which Operative
Approach Is Associated With The Best Outcomes?

Decompressive Craniectomy Versus Craniotomy For Acute Subdural
Hematoma
New England Journal of Medicine 2023;388:2219-2229.
The RESCUE-ASDH (Randomized Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation of
Acute Subdural Hematoma) trial was an international, multicenter, pragmatic, randomized trial involving adult
head injury patients who were undergoing evacuation of an acute subdural hematoma.

Decompressive Craniectomy Versus Craniotomy For Acute Subdural
Hematoma
Objective:
To compare outcomes in patients with acute subdural hematoma randomized to treatment with either
decompressive craniectomy (n=222) versus craniotomy (n=228).
Methods:
The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE), an 8-point scale,
ranging from death to “upper good recovery,” at 6 and 12 months.
Craniectomy Craniotomy
Death1 32.2% 30.2%
Vegetative State1 2.8% 2.3%
Wound Complications2 12.2% 3.9%
Additional Surgery With 2 Weeks2 6.9% 14.6%
1No statistically significant difference 2Statistically significant difference

Disability and quality of life
were similar between groups
at 6 and 12 months.

Decompressive Craniectomy
(Bone Flap Left Off)
Craniotomy
(Bone Flap Replaced)
Advantages
• Space to accommodate brain swelling
• Potentially avoids a second operation when
brain swelling progresses following SDH
evacuation
Advantages
• Lower risk of infection
• Preserves normal skull architecture
Disadvantages
• Requires a second operation to replace the bone
flap, with potential complications that include
infection, bone/wound resorption.
Disadvantages
• Longer operative time
• Risk of requiring a second operation if there is
brain swelling and/or if ICP increases
Traumatic Acute SDH — Should The Bone Flap Be Removed Or Replaced?

Acute SDH Requiring Surgical Evacuation
Three More Case Examples From CMC
61-Year-Old
Pedestrian Struck
52-Year-Old
Fall Off Ladder
66-Year-Old
Ground Level Fall

Case #3
A 77-year-old, independently functional male presents to the ED after a
mechanical fall down 6-7 stairs at home.
Further History:
• There is a positive history of loss of consciousness
• His daughter reports that he was confused and slow to respond initially
• He is not taking anticoagulants
• GCS 15, alert and oriented, though occasionally slow to respond
• Pupils are 3 mm and reactive
• Large temporal scalp hematoma

77-Year-Old Fall Down The Stairs
CT Reveals A 6 mm Acute Subdural Hematoma Without Midline Shift
Case #3

Neurosurgery Opted To Admit The Patient For Observation And Serial Head CTs
Case #3

Initial CT
6 mm
No MLS
CT at 6 Hours
11 mm
No MLS
CT at 12 Hours
11 mm
No MLS
MLS = Midline Shift
The Patient
Remained Clinically
Stable And Was
Discharged Home
Following 48 hours
Of Observation.
Case #3

Are There Clinical Decision Rules To Help Reliable
Predict Which SDH Patients Can Be Safely Observed?

A Decision Instrument to Identify Isolated Traumatic SDH at Low Risk of
Neurologic Deterioration, Surgical Intervention, or Radiographic Worsening
Academic Emergency Medicine 2017;24:1377-1386.
Objective:
It was hypothesized that a decision rule (SafeSDH Rule) could identify patients with SDH who are at very low
risk for neurologic decline, neurosurgical intervention, or radiographic worsening.
Methods:
Retrospective review of patients age ≥ 16 with GCS ≥ 13 and CT-documented isolated SDH presenting to a single Trauma
Center ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome
was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was
performed and statistically important variables were utilized to create a logistic regression model.
Results:
340 patients in the derivation set and 304 in the validation set. Mortality was 2.2%; 15.5% required surgery.
Patients were considered low risk if they had none of the following factors: SDH thickness ≥ 5mm, warfarin or
clopidogrel use, GCS < 14, and presence of midline shift on CT.
Derivation Cohort: Sensitivity 98.6%; specificity 37.1%negative likelihood ratio of 0.037.
Validation Cohort: Sensitivity 96.3%, specificity 31.5%; negative likelihood ratio was 0.127.

Objective:
To externally validate the SafeSDH Tool in a unique patient population of 753 patients.
Methods:
Retrospective review of patients aged >16 with a GCS >13 and isolated SDH who presented to 6 EDs from 2005
to 2018. Primary outcome: a composite of neurologic deterioration, neurosurgical intervention, discharge to
hospice, and death. Hematoma thickness, number of hematomas, and midline shift were abstracted from head
imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record.
Results:
Mortality was 2.1%; 26% of patients underwent neurosurgical intervention.
Composite outcome: sensitivity 99% ([95% CI] 97 to 100), and specificity 31% (95% CI 27 to 35).
The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11).
External Validation of a Tool to Identify Low-Risk Patients With Isolated
Subdural Hematoma and Preserved Consciousness
Annals of Emergency Medicine 2023;published ahead of print.

SafeSDH Appears To Be A Useful Tool To Identify Low-
Risk Patients. Addition Validation Will Be Useful.

Case #4
63-year-old female presents to the ED for generalized weakness, dizziness,
and fatigue.
History:
• She complains of chest pain and has a negative ED evaluation for this
• She also complains of worsening intermittent headaches
Initial Examination Shows:
• She is alert and oriented, at her described baseline
• There are no focal neurologic deficits
• There are no external signs of trauma

Large (mostly) isodense
left convexity subdural
hematoma. The right
temporal horn is dilated
compatible with early
hydrocephalus. The
basal cisterns are
crowded but patent.
• Thickness
• Midline Shift
15 mm
13 mm
Case #4

Large (mostly) isodense
hematoma. The right
temporal horn is dilated
compatible with early
hydrocephalus. The
basal cisterns are
crowded but patent.
• Thickness
• Midline Shift
15 mm
13 mm
The patient underwent
bedside twist drill drain
placement.
Case #4

Post-Operative Day #1 Post-Operative Day #23
Case #4

Case #5
36-Year-Old Healthy Male Dropped A Car Tire On His Head At Work 2 Weeks
Prior To His ED Visit. He Complains Of Worsening Headache.
Further History:
• The patient drinks socially and never in excess
• He has stable vital signs and a GCS=15
• He is awake, slow to respond, answering questions appropriately
• He has equal pupils and no focal neurologic deficits

Isodense left convexity subdural hematoma up to 2.2 cm in thickness with a corresponding
1.5 cm rightward midline shift. There is moderate cistern effacement. There is CSF trapping
with unilateral hydrocephalus of the right lateral ventricle posteriorly.
Case #5

This subdural hematoma is loculated and has membranes (➤) that require craniotomy,
rather than bedside twist drill drainage.
The patient underwent a craniotomy and subdural hematoma evacuation.
Case #5

Post-Operatively The Patient Did Well, Returning To His Pre-
Injury Level Of Function And Activity In Two Months.
POD #1 POD #30 POD #60
Case #5

Subacute SDH
Subacute (isodense) SDHs
can be difficult to identify
on CT. Be sure to:
• Use different CT
windows
• Look for subtle clues,
e.g.: midline shift and
asymmetry

Hounsfield
Units
Days
Hyperdense
Isodense
Hypodense
100
20
1 14
Subacute

Subacute Subdural Hematomas
Two More Case Examples From CMC
83-Year-Old
With Frequent Falls
63-Year-Old
Ground Level Fall

Case #6
ED Visit #1
67-year-old male presents with 3 days of headache. He is alert with a GCS = 15
and a non-focal neurological exam.
CT #1: 7 mm acute left convexity SDH
He is discharged after 2 days of observation and 3 unchanged CT scans
ED Visit #2
The patient returns 14 days later with increasing confusion and unsteady gait.
His GCS is 14 and he his slow to respond. There is no focal neurological deficit.
CT #2: large chronic left SDH with mass effect, midline shift, early hydrocephalus.

CT #1: First ED Visit – Acute Left Subdural Hematoma
CT #2: Second ED Visit (14 Days Later) – Chronic Subdural Hematoma

Case #7
59-year-old male presents to the ED for headaches, confusion and gait
instability after he hit his head at work 2 weeks prior.
History:
• No loss of consciousness, has symptoms of concussion
• Gait instability and confusion is noted by the patient’s wife
• He is not using anticoagulants
Initial Evaluation:
• The patient is alert and oriented
• Normal pupillary exam
• Ataxic gait noted on ambulation testing

59-Year-Old Hit Head Two Weeks Ago
Bilateral Chronic Subdural Hematomas
Case #7

Hounsfield
Units
Days
Hyperdense
Isodense
Hypodense
100
20
1 14
1These represent
approximate times.
Chronic

Journal of Neurosurgery 2020;132:1147-1157.
The Incidence Of Chronic Subdural Hematomas From 1990 To 2015 In A
Defined Finnish Population
Objective:
To determine the epidemiology of chronic subdural hematoma (CSDH) over a 26-year period.
Methods:
Retrospective study of all adult patients ≥ 18 years in Pirkanmaa, Finland with CSDH from 1990 to 2015.
Incidence of CSDH (n/100,000) in
different age groups 1990–2015.
Since 1990 the incidence of CSDH
in patients >80 years has tripled!

What Are The Latest Advances In Our Understanding
Of The Treatment Of Chronic Subdural Hematoma?

Chronic Subdural Hematoma Management
A Systematic Review and Meta-analysis of 34829 Patients
Objective:
Current management strategies of CSDHs remain widely controversial. The aim of this study was to
compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural
hematoma (CSDH) patients.
Methods:
Systematic review of meta-analysis of studies from 1970 to 2013 evaluating management strategies for
patients with CSDH.
Results:
A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and
the remaining 234 were observational. We included our unpublished single center series of 834 patients.
See The Next Slide For The Main Study Results

Chronic Subdural Hematoma Management
A Systematic Review and Meta-analysis of 34829 Patients
Comparing percutaneous bedside drainage to OR burr hole evacuation there was no significant difference in:
Mortality RR: 0.69; 95% CI, 0.46–1.05; P = 0.09
Morbidity RR, 0.45; 95% CI, 0.2–1.01; P = 0.05
Cure RR, 1.05; 95% CI, 0.98–1.11; P = 0.15
Recurrence RR, 1; 95% CI, 0.66– 1.52; P = 0.99
Higher morbidity was associated with the use of corticosteroids (RR, 1.97; 95% CI, 1.54–2.45; P = 0.005)
The use of postoperative drains resulted in decreased recurrences (RR, 0.46; 95% CI, 0.27–0.76; P = 0.002)
Craniotomy was superior to minimally invasive procedures in the management of recurrences
(RR, 0.22; 95% CI, 0.05–0.85; P = 0.003).

Dexamethasone Versus Surgery For Chronic Subdural Hematoma
Objective:
To compare clinical outcomes in patients treated with burr-hole drainage versus tapered dexamethasone.
Methods:
Multicenter, randomized trial. The primary end point was the functional outcome at 3 months, as
assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]).
Results:
• 252 of 420 were enrolled: 127 in the dexamethasone group and 125 in the surgery group.
• The trial was terminated early due to safety and outcome concerns in the dexamethasone group.
• Complications occurred in 59% of the patients in the dexamethasone group and 32% of those in the
surgery group, and additional surgery was performed in 55% and 6%, respectively.
Conclusion:
Patients who received dexamethasone more frequently underwent additional surgery and had more
adverse events than patients who initially had surgical drainage.

JAMA Neurology 2023;80(1):58-63.
Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of
Chronic Subdural Hematoma A Randomized Clinical Trial
Objective
To assess the effect of the physical property of irrigation fluid [body (BT) vs room temperature (RT)] on
recurrence rates following the evacuation of chronic subdural hematoma (cSDH).
Methods:
Randomized trial at 3 centers in Sweden between 2016 and 2020. Study participants were randomly
assigned to the evacuation procedure with irrigation fluid at room temperature or at body temperature.
Outcomes were recurrence requiring reoperation within 6 months and mortality.
Results:
At 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8]) had completed follow-up. There were
no significant differences in mortality, health-related quality of life, or complication frequency.
Recurrence
Room Temperature 39/277 (13%)
Body Temperature 16/264 (6%)
OR: 2.56; 95% CI, 1.38-4.66; P < .001

Operative Neurosurgery 2023;24:469-475.
Middle Meningeal Artery Embolization For Chronic Subdural Hematoma:
A Review
The goal of middle meningeal artery embolization (MMAE) is to devascularize the subdural neomembranes to
such an extent that the balance of accumulation and reabsorption of blood products in the subdural space is
shifted towards reabsorption. As such, MMAE has been used in the following clinical scenarios:
1. Asymptomatic patients with the goal of avoiding the development of symptoms or hematoma growth,
2. Mildly symptomatic patients, with the goal of reducing symptoms and the risk of hematoma growth,
3. As an adjunct to surgical drainage (either preoperative or postoperative) with the goal of reducing the
postsurgical re-accumulation risk and subsequent need for repeated intervention(s),
4. For patients who are coagulopathic, on antiplatelet therapy and/or those who can not endure surgery.

Operative Neurosurgery 2023;24:469-475.

Neurosurgery 2021;88(2):268-277.
Meningeal Artery Embolization for Chronic Subdural Hematoma:
A Multi-Center Experience of 154 Consecutive Embolizations
Objective:
To determine the safety and efficacy of middle meningeal artery embolization (MMAE).
Methods:
Review of consecutive patients who underwent MMAE for chronic SDH at 15 U.S. Trauma Centers.
Results:
• A total of 138 patients were included (mean age 69.8, 29% female).
• At presentation 30% of patients were on antiplatelet therapy and 24% were anticoagulated.
• 46% of embolizations were performed under general anesthesia, 97% were successful.
• 71% of patients had >50% improvement on imaging and 32% improved clinically.
• 9 patients (6.5%) required further chronic SDH management.
Conclusions
Middle meningeal artery embolization provides a safe and effective alternative to conventional surgery.

Chronic Subdural Hematoma
Three Case Examples From CMC
67-Year-Old
Two Weeks of Atraumatic Headache
72-Year-Old
Confusion and Frequent Falls
61-Year-Old
Ground Level Fall

Acute On Chronic SDH
71-Year-Old With Recurrent Falls
Acute
(Hyperdense)
Chronic
(Hypodense)

Acute-on-Chronic Subdural Hematoma
Acute
(Hyperdense)
Chronic
(Hypodense)
61-Year-Old Presents After A Fall At Home

Case #8
87-year-old male with a history of dementia and hypertension presents with
family for the evaluation of altered mental status unsteady gait.
History:
• No known history of trauma
Initial Evaluation:
• Normal vital signs, alert, fluent speech
• Pupils are equal, no facial droop
• Symmetric strength, slight pronator drift

Large mixed density
[acute on chronic]
hematoma with midline
shift and several
membranes visualized
within (➤).
Case #8
➤

The dura is reflected and the thick
membrane superficial to the
subdural hematoma visualized.
The membrane is sharply opened and
cauterized and the hematoma evacuated

Case #9
73-year-old female presents to the ED after fall at home yesterday with
subsequent development of headache and facial bruising.
History:
• Her sister checked on her the next morning and noted the bruising, and
that she was slightly more confused than baseline
• She is on apixaban for atrial fibrillation
Initial Evaluation:
• Hypertensive with otherwise stable vital signs
• Alert but disoriented to the details of the fall
• Periorbital ecchymosis noted bilaterally

73-Year-Old Fall At Home
Acute 6 mm Parafalcine Subdural Hematoma
Case #9

Parafalcine
SDH
Tentorial
SDH
Parafalcine SDHs Are Seen
Adjacent To The Falx Cerebri
Tentorial SDHs Layer On Top Of
The Tentorium Cerebelli.
These Can Be Subtle!
From: www.EMguidwire.com – July 2023.

71-Year-Old Car Crash
53-Year-Old Car Crash
Parafalcine Subdural Hematomas
Two Case Examples From CMC

25-Year-Old Pedestrian Struck
Tentorial Subdural Hematomas
A Recent Case From CMC

What Is The Natural History Of Patients With Acute
Parafalcine And Tentorial Subdural Hematomas?

Methods:
Retrospective, single Level-1 Trauma Center review to assess the outcomes of 65 adult patients with
isolated tentorial and parafalcine subdural hematomas.
Results:
• 90% of patients were admitted to the ICU regardless of their presenting GCS
• 94% of patient had repeat imaging although none had radiographic progression of their SDH
• A GCS ≤12, the presence of other injuries, and being elderly was associated with worse outcomes
Conclusions:
Patients with isolated tentorial and parafalcine subdural hematoma who remain alert and who lack other
important injuries: (1) can be observed in a non-intensive care level setting, and (2) do not require
”routine” repeat CT imaging unless their clinical condition worsens.
Management and Outcomes Of Isolated Parafalcine And Tentorial Hematoma
Journal of Neurotrauma 2017;34:128-136.

Methods:
Retrospective, single center review comparing radiographic and clinical outcomes in patients with
parafalcine subdural hematomas (SDH) versus patients with convexity subdural hematomas.
Outcome Parafalcine (n=88) Convexity (n=228) P-value
Radiographic Progression 6 (6.8%) 48 (21.1%) <0.005
Neurologic Deterioration 0 (0%) 49 (21.5%) <0.005
Surgical Procedure Required 0 (0%) 35 (15.4%) <0.005
Mortality Or Hospice 0 (0%) 37 (16.2%) <0.005
Conclusions:
Patients with isolated parafalcine SDH represent a relatively benign condition as compared with convexity
SDH and do not benefit from repeat imaging or Intensive Care Unit admission.
Journal of Surgical Research 2020;249:99-103.
Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Condition

References: Acute Subdural Hematoma
• Surgical Management Of Acute Subdural Hematoma. Neurosurgery 2006;58:S16-S24.
• Time Interval To Surgery And Outcomes Following The Surgical Treatment Of Acute Traumatic
Subdural Hematoma. Journal of Clinical Neurosciences 2014;21(12):2107-2111.
• Reducing Time-to-Treatment Decreases Mortality of Trauma Patients with Acute Subdural Hematoma.
• Decompressive Craniectomy Versus Craniotomy For Acute Subdural Hematoma. New England Journal
of Medicine 2023;388:2219-2229.
• Traumatic Acute SDH — Should The Bone Flap Be Removed Or Replaced? New England Journal of
Medicine 2023;388:2288-2289.
• A Decision Instrument to Identify Isolated Traumatic SDH at Low Risk of Neurologic Deterioration,
Surgical Intervention, or Radiographic Worsening. Academic Emergency Medicine 2017;24:1377-1386.
• External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and
Preserved Consciousness. Annals of Emergency Medicine 2023;published ahead of print.

References: Chronic Subdural Hematoma
• The Incidence Of Chronic Subdural Hematomas From 1990 To 2015 In A Defined Finnish Population.
Journal of Neurosurgery 2020;132:1147-1157.
• Chronic Subdural Hematoma Management A Systematic Review and Meta-analysis of 34829 Patients.
• Dexamethasone Versus Surgery For Chronic Subdural Hematoma. New England Journal of Medicine
2023;338:2230-2240.
• Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma
A Randomized Clinical Trial. JAMA Neurology 2023;80(1):58-63.
• Middle Meningeal Artery Embolization For Chronic Subdural Hematoma: A Review. Operative
Neurosurgery 2023;24:469-475.
• Kan P. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center
Experience of 154 Consecutive Embolizations. Neurosurgery 2021;88(2):268-277.

References: Parafalcine Subdural Hematoma
• Management and Outcomes Of Isolated Parafalcine And Tentorial Hematoma. Journal of
Neurotrauma 2017;34:128-136.
• Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Condition. Journal of Surgical Research
2020;249:99-103.

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