eMedicine Specialties > Neurosurgery > Trauma

Subdural Hematoma: Workup

Author: Herbert H Engelhard III, MD, PhD, FACS, Director, UIC Neuro-Oncology Program, Chief, Division of Neuro-Oncology, Associate Professor, Department of Neurosurgery, University of Illinois at Chicago
Coauthor(s): Grant P Sinson, MD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin; G Timothy Reiter, MD, Assistant Professor, Department of Neurosurgery, Penn State College of Medicine; Director, Department of Spinal Neurosurgery and Neurotrauma, Penn State Hershey Medical Center
Contributor Information and Disclosures

Updated: Jul 31, 2009

Workup

Laboratory Studies

  • Initial blood tests

    • To determine if defective coagulation was involved in the formation of the subdural hematoma (SDH) and to guide correction of any coagulation abnormalities, a prothrombin time (PT), activated partial thromboplastin time (aPTT), and a platelet count are typically performed. A bleeding time assessment may reveal platelet dysfunction.
    • Routine trauma laboratory studies that aid in the initial patient assessment may include hemoglobin or hematocrit, electrolytes, and a drug and alcohol screening. The drug and alcohol screenings may be important for correlating the neurological examination with the imaging studies.

Imaging Studies

  • CT scan of the head (without contrast)
    • An emergent head CT scan needs to be performed when an acute subdural hematoma (SDH) is suspected and should be obtained immediately after the patient is stabilized using standard advanced trauma life support (ATLS) guidelines.
    • An acute SDH appears on the noncontrast head CT scan as a crescent-shaped hyperdense area between the inner table of the skull and the surface of the cerebral hemisphere (see Image 7). Acute SDHs are usually unilateral.
    • A small acute SDH may be difficult to appreciate because of the appearance of the overlying skull. Use of the bone window setting may aid in discrimination.
    • An SDH may also be located along the falx (ie, interhemispheric), along the tentorium, or in the posterior fossa. Interhemispheric SDHs are among the findings identified in some abused children. Rarely, a SDH appears –lens shaped (ie, more like an epidural hematoma).
    • All or part of an acute SDH may appear hypodense or isodense to brain if the patient’s hematocrit is low, if the clot is hyperacute (eg, <1 hour old), if the subdural space contains active bleeding, if coagulopathy is present, or if the CSF if creating a dilutional effect. Detection of an isodense SDH may require a high index of suspicion; subtle changes in the appearance or position of the cortical sulci may be found. Contrast-enhanced CT or MRI may help to better define the lesion. Interestingly, isodense SDHs may be either hypointense or hyperintense on T2-weighted MRI; this may be a clue to the underlying pathophysiology.14
    • The characteristic evolution of an SDH appearance on CT scan is as follows: In the first week, the SDH is hyperdense to brain tissue. In the second and third weeks, the SDH appears isodense to brain tissue (see Images 3-4). After the third week, the SDH is hypodense to brain tissue.
    • Often, a chronic SDH appears as a heterogeneously dense lesion indicative of recurrent bleeding with a fluid level between the acute (hyperdense) and chronic (hypodense) components of the hematoma (see Image 2).
      • On a contrast-enhanced CT scan, the chronic SDH membrane enhances to varying degrees, depending on numerous factors. Sometimes, a contrast-enhanced scan shows evidence of an underlying cause, such as a tumor or vascular lesion (eg, in patients with acute but nontraumatic SDH).
      • Typical signs of mass effect, such as midline shift and ventricular compression, may be observed.
  • Magnetic resonance imaging
    • MRI is less useful than CT in diagnosing an acute SDH because of the increased time needed to obtain the study and the inability to use metallic objects that are needed to resuscitate patients with trauma (eg, most ventilators) in the scanning environment.
    • MRI can be a useful study to evaluate associated parenchymal brain injury and predict prognosis, but only after stabilizing and treating any life-threatening lesions. MRI is more sensitive for detecting nonhemorrhagic brain lesions, contusions, and diffuse axonal injury.15
    • An MRI is helpful in imaging chronic SDH when CT scans are difficult to interpret (eg, when suspecting an isodense hematoma). MRI may be particularly helpful in diagnosing bilateral chronic SDH because a midline shift may not be apparent on CT scan.

Histologic Findings

Acute subdural hematomas (SDHs) usually contain both liquid and clotted blood. Intact erythrocytes are usually found within the clot. Associated skull fractures and underlying focal traumatic parenchymal damage are often present.

Fibroblastic membranes form on the dural side and arachnoid side of the chronic SDH, with the dural neomembrane being more vascular. The neomembrane consists of many capillaries, intact and lysed erythrocytes, hemosiderin-laden macrophages, and granulation tissue.

More on Subdural Hematoma

Overview: Subdural Hematoma
Workup: Subdural Hematoma
Treatment: Subdural Hematoma
Follow-up: Subdural Hematoma
Multimedia: Subdural Hematoma
References
Further Reading
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References

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Further Reading

Clinical guidelines

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE, Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery 2006 Mar;58(3 Suppl):S2-16-S2-24. 13

Davis PC, Seidenwurm DJ, Brunberg JA, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ, Zimmermam RD, McDermot MW, Sloan MA, Expert Panel on Neurologic Imaging. Head trauma. ACR Appropriateness Criteria® head trauma [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 12 p.

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Keywords

subdural hematoma, SDH, subdural hematomas, subdural hemorrhage, subdural hemorrhages, acute subdural hematoma, ASDH, subacute subdural hematoma, chronic subdural hematoma, CSDH, intracranial hemorrhage, brain bleed, brain bleeding, contralateral hematoma, subdural hygroma, dementia

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Contributor Information and Disclosures

Author

Herbert H Engelhard III, MD, PhD, FACS, Director, UIC Neuro-Oncology Program, Chief, Division of Neuro-Oncology, Associate Professor, Department of Neurosurgery, University of Illinois at Chicago
Herbert H Engelhard III, MD, PhD, FACS is a member of the following medical societies: American Association for Cancer Research, American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, American Society for Cell Biology, Chicago Medical Society, Congress of Neurological Surgeons, Illinois State Medical Society, Society for Neuro-Oncology, and Society for Neuroscience
Disclosure: Nothing to disclose.

Coauthor(s)

Grant P Sinson, MD, Associate Professor, Department of Neurosurgery, Medical College of Wisconsin
Grant P Sinson, MD is a member of the following medical societies: American Association of Neurological Surgeons and American Medical Association
Disclosure: Nothing to disclose.

G Timothy Reiter, MD, Assistant Professor, Department of Neurosurgery, Penn State College of Medicine; Director, Department of Spinal Neurosurgery and Neurotrauma, Penn State Hershey Medical Center
G Timothy Reiter, MD is a member of the following medical societies: American Association of Neurological Surgeons
Disclosure: Synthes Spine Consulting fee Consulting; Integra Grant/research funds None

Medical Editor

Paul L Penar, MD, Professor, Department of Surgery, Division of Neurosurgery, University of Vermont School of Medicine
Paul L Penar, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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