This document describes the case of a 56-year-old male who presented with drowsiness and vomiting after a fall and head injury. On examination, he had a Glasgow Coma Scale of 13/15. Imaging showed a subdural hematoma. He underwent surgical evacuation of the subdural hematoma. The document then provides background information on subdural hematomas including causes, risk factors, classification, signs and symptoms, diagnosis using CT scans, and treatment options including conservative management or craniotomy. Guidelines for management of mild, moderate and severe traumatic brain injuries are also summarized.

1. Subdur al
Hematoma
Dr. Monsif Iqbal
PGT
Surgery Deptt.
P.O.F. Hospital

2. Case
Presentation

3. PATIENT’s PROFILE:
 Name: M. Riaz
 Age: 56 yrs.
 Sex: Male
 Address : Attock.
 D.O.A: 21-03-2010
 M.O.A: ER

4. PRESENTING COMPLAINTS
 H/O fall, with head injury – 2 hrs
 Drowsiness
 Vomiting

5. PAST HISTORY
 RTA, with head injury --- 3 years back
 No significant past medical illness

6. Drug HISTORY
 No history of warfarin, or aspirin intake

7. PERSONAL HISTORY
 Non smoker
 No history of drug addiction or
dependence.

8. PHYSICAL EXAMINATION:
1. GPE:
A middle aged gentleman, lying in bed
confused and Drowsy
His vitals are;
 Pulse: 100/min
 B.P: 130/80 mm of Hg
 Oxygen Sat: 96%
 Temp: Afebrile
Rest of GPE unremarkable.

9. NEUROLOGICAL
EXAMINATION:
 GCS 13/15
 Pupils – Bilaterally reactive to light
 No Obvious injury on the scalp
 Rest of the systemic exam ---
unremarkable

10. Investigations on the
day of admission
 Xrays Skull AP and lateral views
 Blood CP
 BSR

11. INVESTIGATIONS:
1. Blood CP:
 Hb ---- 13.4 gm/dl
 TLC ---- 15.5x103/ul
 PLT ---- 242x103/ul
2. BSR:90 mg/dl

12. X-ray Skull AP view

13. X-ray skull lateral view

14. Management
 NPO
 IV fluids (Ringer lactate)
 IV Antibiotics
 Pain Killers
 Input/output record

15. CT Scan Brain

16. CT Scan Brain

17. Surgical Management
 Surgical evacuation of the subdural
hematoma under G/A

18. Subdural Hematoma
 A subdural hematoma (SDH)
is a form of traumatic brain
injury in which blood gathers
between the dura and the
arachnoid.

19. Pathophysiology
 Unlike in epidural hematomas, SDH usually results from the tears
in veins.
 Further expansion due to osmosis
 In some subdural bleeds, the arachnoid layer of the meninges is
torn
 Local vasoconstrictors
 May be reabsorbed, a subdural hygroma may be formed

20. Classification scheme
 Acute SDH (upto 7 days)
 Sub acute SDH (7-21 days)
 Chronic SDH (more than 21 days)

21. Risk Factors
 Extreme of age
 Anticogulants
 Long term Alcohol Abuse

22. Clinical Features of
 A history of recent head SDH
injury
 Loss of consciousness or fluctuating levels of consciousness
 Irritability
 Seizures
 Numbness
 Headache (either constant or fluctuating)
 Dizziness
 Disorientation
 Amnesia
 Weakness or lethargy
 Nausea or vomiting
 Personality changes
 Inability to speak or slurred speech
 Ataxia, or difficulty walking
 Altered breathing patterns
 Blurred Vision

23. Extradural Hematoma Subdural Hematoma
 Biconvex or lenticular  Diffuse and concave
 Temporal or  Entire surface of brain
temporoparietal
 Middle meningeal artery  Tearing of bridging veins
 0.5% of all head injured  30% of severe head
pts injuries
 “Lucid” interval classically  Underlying brain damage
more severe
 Outcome related to status  Prognosis is worse than
prior to surgery extradural

24. Diagnosis
 It is important that a patient receive
medical assessment, including a
complete neurological examination, after
any head trauma. A CT scan will usually
detect significant subdural hematomas.

25. 8.2. Non-contrast CT Brain 8.2 Non-contrast CT Brain
Acute and subacute Subdural CT Density 72.9 HU
Hematoma

26. 8.3a. Non-contrast CT Brain
Chronic Subdural Hematoma

28. 8.4a. Non-contrast CT Brain 8.4b. Non-contrast CT Brain 8.4c. Non-contrast CT Brain
Subarchnoid hemorrhage

29. .
8.5 Non-contrast CT Brain

30. 8.1. Non-contrast CT Brain 8.1 Non-contrast CT Brain
CT Density 68.6 HU
Acute Intracerebral hematoma

31. Treatment
 Small Subdural hematomas ---
Conservative management
 Large or Symptomatic --- Craniotomy

32. Management of Mild
Head Injury (GCS
14-15)
 About 3% of these patients deteriorate unexpectedly,
resulting in severe neurological dysfunctions unless the
decline in mental status is noticed early
 Ideally, a CT scan should be obtained in all head-injury
patients, especially if there is a history of more than a
momentary loss of consciousness, amnesia, or severe
headaches.

33. NICE guidelines for CT
in Head Injury
 GCS < 13 at any point
 GCS 13 or 14 at 2 hours
 Focal Neurological deficit
 Suspected open, depressed or basal skull fracture
 Seizure
 Vomiting > one episode
Urgent CT if none of the above but
 Age > 65
 Coagulopathy (e.g. on warfarin)
 Dangerous mechanism of injury (CT within 8 hours)
 Antegrade amnesia > 30 minutes

34. Management of Mild
Head Injury (GCS
14-15) (cont.)
 At present, skull x-rays are recommended only in
penetrating head injury or when CT scanning is not
immediately available
 X-rays of the cervical spine must be obtained if there is
any pain or tenderness.

35. Management of
Moderate Head
Injury(GCS 9-13)
 Approximately 10% to 20% of these patients
deteriorate and lapse into coma. Therefore, they
should be managed like severely head-injured patient
 They are not routinely intubated. However every
precaution should be taken to protect the airway

36. Management of severe
Head Injury (GCS 3-8)
 In a comatose patient (GCS 8 or below) secure and
maintain the airway by endotracheal intubation
 Moderately hyperventilate the patient to reverse
hypercarbia, maintaining the PCO2 between 25 and 35
mm Hg
 Treat shock aggressively and look for its cause
(consider DPL)
 Resuscitate with normal saline, Ringer’s lactate or
similar isotonic solutions without dextrose. Do not use
hypotonic solutions. Avoid both hypovolemia and over
hydration, achieving a euvolemic state.

37.  Perform a neurologic examination after normalizing the
blood pressure and before paralyzing the patent. Avoid
the use of long-acting paralytic agents.
 All severe and most modetate head injury patients
require a CT scan to exclude mass lesions
 Search for associated injuries. Exclude cervical spine
injuries radiographically and clinically
 Contact a neurosurgeon as early as possible. If a
neurosurgeon is not available at your facility, transfer
all moderately or severely head-injured patients
 Frequently reassess GCS

38. THANKS