eMedicine Specialties > Radiology > Brain/Spine
Subdural Hematoma
Updated: Oct 29, 2009
Introduction
Background
Subdural hematomas (SDH) are 1 of the 3 types of extra-axial intracranial hemorrhages (along with subarachnoid and epidural hemorrhages) and usually occur as a result of trauma. Deceleration injuries are often the cause of subdural bleeding from rupturing of veins via a shearing mechanism. Other entities, such as child abuse and ventricular decompression, also can result in subdural bleeding, and spontaneous hemorrhages may occur in patients receiving anticoagulants or patients with a coagulopathy condition. Compression of a dural sinus does not directly cause a subdural hematoma, although compression may result in a venous infarction.
Some subdural hematomas are clinically silent, whereas others cause symptoms as a result of mass effect on the adjacent brain. Some hematomas can grow large enough to result in herniation of cerebral tissue. Before computed tomography (CT) scanning and magnetic resonance imaging (MRI) technology, subdural hematomas were diagnosed only on the basis of this mass effect, which was depicted as displacement of the blood vessels on angiograms or as a calcified pituitary gland on skull radiographs. The advent of CT scan and MRI studies has made the diagnosis of even small hemorrhages routine (see Image 1).
Axial head computed tomography scan demonstrates a skull fracture with an adjacent, small subdural hematoma. Window and level values are widened over standard values, which aids in the detection of small hemorrhages.
Recent studies
Domenicucci et al described the anatomic, clinical, and neuroradiologic features and outcome in a series of 8 patients whose ipsilateral chronic SDH associated with an arachnoid cyst were managed surgically by draining the hematoma alone through a bur hole and leaving the cyst intact. Postoperative follow-up CT and T1- and T2-weighted MR imaging suggested that arachnoid cysts related to hematoma contained only blood breakdown products from the hematoma that had filtered through the reciprocal dividing membranes. According to the authors, arachnoid cysts associated with SDH are anatomically separate conditions whose neurologic symptoms respond to surgical drainage of the SDH alone.[1 ]
Using xenon-enhanced CT, Chieregato et al measured the Glasgow Outcome Scale (at 12 months) values and the time course of regional cerebral blood flow (rCBF) in the cortex beneath an evacuated acute SDH and their relation to neurologic outcome in 20 patients with moderate or severe traumatic brain injury and an evacuated SDH. Findings were compared with those of a control group of 23 patients with moderate or severe traumatic brain injury and an evacuated extradural hematoma or diffuse injury. The investigators found that hyperemic long-lasting rCBF values frequently occurred in the cortex beneath an evacuated SDH and was often associated with unfavorable outcome. Side-to-side differences of rCBF and rCBFmax levels between lesioned and nonlesioned hemispheres were greater in patients with an evacuated SDH, and side-to-side differences in the rCBFmax values were higher in SDH patients with unfavorable outcome at 24-96 hours and at 4-7 days. In addition, SDH thickness and midline shift were greaterin patients with an unfavorable outcome.[2 ]
Petridis et al used CT and neurologic deficits caused by acute SDH to define outcome and surgical management in patients 65 years or older. The authors found that expected outcome is very good in such patients with a Glasgow Coma Scale (GCS) score of 13-15, and these patients can therefore be observed clinically; however, comatose patients (GCS 3-8) with bilateral dilatation of the pupils should not undergo operation because of very high asociated mortality. They observed that surgery is indicated if the GCS score is less than 13, one or both pupils are reactive to light, and the midline shift is less than 10 mm. If the midline shift is greater than 10 mm and acute SDH thickness is greater than the midline shift, surgery may also be indicated, but if in the same patient group midline shift is greater than SDH thickness and intracranial pressure is 40 mm Hg, surgery is not indicated, as these are unfavorable factors, according to the investigators.[3 ]
For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Head Injury, Concussion, and Aneurysm, Brain.
Pathophysiology
The meninges are composed of the dura mater, arachnoid mater, and pia mater. A space potentially exists between the arachnoid and dura (termed the subdural space), which, unlike the epidural space, is not confined by the cranial sutures. Bridging veins cross this space, extending from the cortical surface into the dural sinuses. Bleeding from these veins may occur as a result of a shearing injury (either by rotational or linear forces) along the plane of the subdural space and traumatic stretching of the veins, which can occur from rapid ventricular decompression.Because the subdural space is not limited by the cranial sutures, blood can spread along the entire hemisphere and into the hemispheric fissure, limited only by the dural reflections (see Image 2). This ability of blood to spread relatively unchecked results in a crescent-shaped subdural hemorrhage rather than the biconvex or football shape of most epidural hematomas.
Subacute subdural hematoma with extension into the anterior interhemispheric cistern. Note that the sutures do not contain the spread of these hemorrhages.
In larger, more clinically important subdural hematomas, the etiology of the bleeding is often an adjacent cortical laceration or shearing of cortical vessels. Patients with these hematomas have a worse prognosis; some studies report mortality rates in excess of 80%.
Most subdural hematomas occur along the cerebral convexities. Less common locations include the posterior fossa and along the interhemispheric fissure and tentorium (see Image 3).
Tentorial subdural hematoma in an adult with trauma. In children with this pattern of injury, abuse should be considered.
In children, subdural hematomas occurring along the posterior interhemispheric fissure and the tentorium have been described as common findings following violent nonaccidental shaking (ie, shaken baby syndrome). Although these hematomas are not pathognomonic for child abuse, they should always suggest the possibility of abuse. It should be noted, however, that in children with benign external hydrocephalus, subdural hematomas and retinal hemorrhages may occur following even minor trauma.
In addition, a study by Tung et al revealed no statistically significant difference in the incidence of interhemispheric subdural hematomas in accidental trauma relative to nonaccidental trauma in children, raising the possibility that such injuries are not a reliable method for detecting child abuse. The authors did note, however, a higher incidence of mixed-density subdural hematomas in nonaccidental trauma.[4 ]
Although the vast majority of subdural hematomas result from trauma, spontaneous subdural hematomas can be seen in elderly individuals, those receiving anticoagulation, or patients with intracranial hypotension. Subdural hematomas after lumbar puncture, epidural injection, and puncture of spinal meningeal cysts have been reported. Patients with polycystic kidney disease and Prader-Willi syndrome also have an increased risk for spontaneous subdural hematomas.
Rare occurrences of subdural hematomas resulting from ruptured aneurysms (see Image 4) or dural arteriovenous malformations have been described. These diagnoses should be considered in cases of unexplained subdural hematomas, particularly recurrent subdural hematomas, which may be caused by intermittent bleeding from a dural arteriovenous malformation.
Subdural hematoma with adjacent subarachnoid hemorrhage was the result of a ruptured middle cerebral artery aneurysm. Aneurysms are unusual causes of subdural hematomas.
Another rare cause of chronic subdural hematomas is an arachnoid cyst. The hematoma may be preceded by cyst rupture and formation of a subdural hygroma with subsequent bleeding into the space.
Subdural hematomas are more common in the elderly and in infants because both groups have a larger subarachnoid space than young adults. The larger subarachnoid space allows for more movement between the brain and dura, predisposing these populations to the formation of subdural hematomas.
Frequency
United States
The frequency varies because many subdural hematomas are caused by trauma. One study of chronic subdural hematomas showed that this type of hematoma occurs at a rate of about 1 case per 10,000 population.
Mortality/Morbidity
- In patients with small subdural hematomas ( <1 cm in diameter), the prognosis is good. One study showed that 78% of patients undergoing burr-hole evacuation of chronic subdural hematomas had a good or complete recovery.
- Clinical outcome in patients with acute subdural hematomas is not as good because of the presence of other injuries and because of selection bias. In patients with subdural hemorrhages large enough to warrant surgery, mortality exceeds 50% and is related to the size of the hematoma and the amount of midline brain shift. However, the most important feature used to predict the outcome is the absence or presence of adjacent parenchymal contusion.
- Mortality in patients with large subdural hematomas causing mass effect on adjacent brain tissue is improved if the hemorrhage is treated surgically within 4 hours after injury. Although patients with large subdural hematomas do better when the hematoma is evacuated within the first 4 hours, a longer wait does not necessarily result in death.
Age
Subdural hematomas may occur at any age as a result of various types of trauma. In children, shaken baby syndrome usually occurs before the age of 1 year. In older persons, a subdural hematoma is more likely related to a fall. Both the elderly and infants are predisposed toward subdural hematomas because of their relatively large subarachnoid spaces.
Anatomy
See Pathophysiology.
Presentation
Subdural hematomas may be clinically silent when small and discovered only when imaging of the brain is performed as part of the workup for trauma. Some patients may complain of headache or dizziness when an isolated subdural hematoma is present. When the hematoma is larger, symptoms usually result from mass effect on the brain tissue or from adjacent parenchymal injuries. Decreased mental status, unsteady gait, headache, deviated gaze, and respiratory depression may be presenting symptoms.[5,6 ]
Preferred Examination
CT scanning is usually the first evaluation in patients with suspected acute subdural hematoma because CT scans depict acute hemorrhage and skull fractures well, they are relatively fast to obtain, and CT scanning is more readily available than MRI. Smaller hemorrhages may be missed on CT scans, and in the nonacute setting, MRI is the study of choice because of its high sensitivity and specificity.[7,8 ]
Limitations of Techniques
CT scanning may fail to depict small hemorrhages because of the similarity in attenuation between blood and adjacent bone and because of streak artifacts in the posterior fossa and inferior middle cranial fossa. MRI aids in the detection of small hematomas because of its multiplanar capabilities.
Differential Diagnoses
Arachnoid Cyst
Epidural Hematoma
Other Problems to Be Considered
Brain atrophy
Radiography
Findings
In the past, the finding of pineal gland displacement on skull radiographs was used as an indication of the presence of intracranial hemorrhage, but this is no longer clinically relevant.
Computed Tomography
Findings
CT scan findings in subdural hematomas depend on the age of the hemorrhage.[4,9,10 ]
In the acute phase, subdural hematomas appear as a crescent-shaped extra-axial collection with increased attenuation that, when large enough, causes effacement of the adjacent sulci and midline shift. The attenuation changes as the hematoma ages (see Images 5-6).
Late subacute subdural hematoma has decreased attenuation compared with adjacent brain tissue. Attenuation of the hematoma remains higher than that of cerebrospinal fluid.
Computed tomography scan in a patient with a subacute right frontal subdural hematoma. The blood has the same attenuation as that of the adjacent gray matter and is difficult to distinguish. Note that the gray matter–white matter junction is displaced medially, and midline shift is seen, indicating the presence of a space-occupying extra-axial lesion.
Subacute subdural hematomas may be difficult to detect because they may have isoattenuation compared with adjacent gray matter (see Image 7). Displacement of the gray matter–white matter junction is an important sign that indicates the presence of a space-occupying lesion. Although often administered in the past to help detect displacement of cortical vessels, contrast medium is not necessary with the capabilities of current scanners.
Late subacute-to-chronic subdural hematoma with a blood-fluid level indicating acute hemorrhage into the chronic collection.
Chronic subdural hematomas have isoattenuation relative to the cerebrospinal fluid (CSF). In rare cases, such hematomas may calcify, resulting in an unusual appearance that can be mistaken for a calcified mass.
Unlike epidural hematomas, subdural hematomas are not restricted by dural tethering at the cranial sutures; they can cross suture lines and continue along the falx and tentorium. However, they do not cross the midline because of the meningeal reflections.
When a subdural hematoma is discovered on a CT scan, it is important to check for the presence of other related injuries, such as skull fracture (see Image 1), intraparenchymal contusions, and subarachnoid blood. The presence of adjacent parenchymal injury in patients with a subdural hematoma is the most important factor in predicting their clinical outcome.
Rebleeding into subdural hematomas also may occur and is depicted as a layer of high-attenuation hemorrhage within a lower attenuation hematoma (see Image 7).
Degree of Confidence
Differentiating subdural from epidural hematomas may be difficult when the hemorrhage is small, because the image of the blood may not demonstrate a typical shape in either condition. Follow-up imaging to ensure that the hematoma is not expanding and to check for an adjacent skull fracture is typical.
False Positives/Negatives
Small subdural hematomas may not be depicted because the attenuation may be similar to the adjacent inner table of the skull. Viewing the images with a wider window and level (eg, 240 and 80 HU) assists in detection in these cases (see Image 1); however, CT scanning fails to depict a certain number of small hemorrhages. Gentry et al found that only 53% of acute and subacute subdural hematomas were revealed on CT scan studies compared with MRI; however, this study was performed using older CT technology.[11,12 ]
In older patients with cerebral atrophy, an appearance of bilateral frontal subdural hygromas may be seen when the patient is in the supine position. However, the lack of mass effect and the presence of general atrophy suggest that this appearance is merely the result of settling of the atrophic brain rather than a pathologic subdural collection. A similar finding can be seen in young children (benign enlargement of the subarachnoid space), which should resolve in the first few years of life (see Image 8).
Axial computed tomography scan demonstrates the benign enlargement of the subarachnoid space that occurs in children. The extra-axial fluid does not cause mass effect and normally resolves within the first 2 years of life.
Posttraumatic subdural hygromas can also be confused with chronic subdural hematomas. These develop days or weeks following trauma and result from tears in the arachnoid and resulting leakage of CSF into the subdural space. They are self-limited and usually resolve after several months.
Magnetic Resonance Imaging
Findings
MRI is more sensitive than CT scanning in the detection of subdural hematomas because the multiplanar and superior tissue differentiation of MRI makes detection easier. In particular, a sensitivity of more than 95% has been described with T2-weighted images of subdural hematomas because of the marked difference in signal intensity between blood products and adjacent structures (see Images 9-10).
Axial T1-weighted magnetic resonance imaging demonstrates bilateral subacute subdural hematomas with increased signal intensity. Areas of intermediate intensity represent more acute hemorrhage into the subacute collections.
T2-weighted magnetic resonance imaging in a patient with subdural hematoma shows blood products of differing ages (same patient as in Image 8).
The shape of the subdural hematoma on axial images is the same crescent-shaped pattern seen on CT scan images. Coronal images are useful in evaluating the extent of subdural hematomas and in detecting temporal and tentorial hemorrhages, 2 aspects that are poorly depicted on CT scans.
In subdural hematomas, the signal depends on the age of the hemorrhage and follows the signal pattern of intraparenchymal hematomas in acute and subacute cases (see Brain, MRI Appearance of Hemorrhage). Chronic subdural hematomas, which appear as isoattenuation relative to CSF on CT scans, often demonstrate increased signal intensity on T1-weighted images because of the presence of free methemoglobin, though the intensity decreases over time. Hemosiderin is usually not present and is believed to result from the lack of a dural blood–brain barrier.
T2-weighted magnetic resonance imaging in a patient with a subdural hematoma and rebleeding clearly shows hemorrhages of 3 different ages; these are hyperintense, isointense, and hypointense relative to brain tissue.
Computed tomography (CT) scan demonstrating a patient with subdural hematomas of varying ages. This patient had a CT 1 week prior that demonstrated a chronic subdural hematoma (represented by the low density fluid on this study). Over the next week, his clinical condition progressively declined, then he collapsed shortly before this image was obtained. The gray blood represents subacute hemorrhage, whereas the white blood represents acute.
When hemorrhages of differing ages exist within a subdural collection, septae may separate the different blood products (see Image 11). In addition, a blood–fluid level may be seen. When blood products of various ages are depicted on MRIs in a child, particularly when the blood is at multiple sites, child abuse must be suspected (see Image 12). Posterior interhemispheric and tentorial subdural hematomas are also suggestive of child abuse because they are associated with shaken baby syndrome.
Degree of Confidence
MRI is the most sensitive imaging test available for the detection of subdural hematomas. Small subdural hematomas are occasionally difficult to distinguish from epidural hemorrhages.
Angiography
Findings
Before the advent of CT scanning and MRI technology, subdural hematomas were often diagnosed by angiography. However, angiography is no longer an appropriate imaging tool in this setting.
Intervention
Medicolegal Pitfalls
- In children, posterior interhemispheric and tentorial subdural hematomas have been associated with child abuse.
- The radiologist should be concerned about possible child abuse when a posterior subdural hematoma is seen, particularly in association with other suggestive imaging results, such as the depiction of blood products of differing ages.
Multimedia
Media file 1: Axial head computed tomography scan demonstrates a skull fracture with an adjacent, small subdural hematoma. Window and level values are widened over standard values, which aids in the detection of small hemorrhages.
Media file 2: Subacute subdural hematoma with extension into the anterior interhemispheric cistern. Note that the sutures do not contain the spread of these hemorrhages.
Media file 3: Tentorial subdural hematoma in an adult with trauma. In children with this pattern of injury, abuse should be considered.
Media file 4: Subdural hematoma with adjacent subarachnoid hemorrhage was the result of a ruptured middle cerebral artery aneurysm. Aneurysms are unusual causes of subdural hematomas.
Media file 5: Late subacute subdural hematoma has decreased attenuation compared with adjacent brain tissue. Attenuation of the hematoma remains higher than that of cerebrospinal fluid.
Media file 6: Computed tomography scan in a patient with a subacute right frontal subdural hematoma. The blood has the same attenuation as that of the adjacent gray matter and is difficult to distinguish. Note that the gray matter–white matter junction is displaced medially, and midline shift is seen, indicating the presence of a space-occupying extra-axial lesion.
Media file 7: Late subacute-to-chronic subdural hematoma with a blood-fluid level indicating acute hemorrhage into the chronic collection.
Media file 8: Axial computed tomography scan demonstrates the benign enlargement of the subarachnoid space that occurs in children. The extra-axial fluid does not cause mass effect and normally resolves within the first 2 years of life.
Media file 9: Axial T1-weighted magnetic resonance imaging demonstrates bilateral subacute subdural hematomas with increased signal intensity. Areas of intermediate intensity represent more acute hemorrhage into the subacute collections.
Media file 10: T2-weighted magnetic resonance imaging in a patient with subdural hematoma shows blood products of differing ages (same patient as in Image 8).
Media file 11: T2-weighted magnetic resonance imaging in a patient with a subdural hematoma and rebleeding clearly shows hemorrhages of 3 different ages; these are hyperintense, isointense, and hypointense relative to brain tissue.
Media file 12: Computed tomography (CT) scan demonstrating a patient with subdural hematomas of varying ages. This patient had a CT 1 week prior that demonstrated a chronic subdural hematoma (represented by the low density fluid on this study). Over the next week, his clinical condition progressively declined, then he collapsed shortly before this image was obtained. The gray blood represents subacute hemorrhage, whereas the white blood represents acute.
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Keywords
subdural hematoma, SDH, subdural hemorrhage, subdural bleed, brain hemorrhage, intracranial hemorrhage, extraaxial hemorrhage, extra-axial hemorrhage, intracranial hemorrhage, cranial bleeding, head trauma, brain injury, brain trauma, acute subdural hematoma, subacute subdural hematoma, chronic subdural hematoma, shaken baby syndrome, shaken-baby syndrome, child abuse
Contributor Information and Disclosures
Author
Andrew L Wagner, MD, Assistant Professor of Radiology, Instructional Faculty, University of Virginia School of Medicine; Director of Neuroradiology, Department of Radiology, Rockingham Memorial Hospital
Andrew L Wagner, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.
Medical Editor
Robert A Koenigsberg, DO, MSc, FAOCR, Professor, Director of Neuroradiology, Program Director, Diagnostic Radiology and Neuroradiology Training Programs, Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine
Robert A Koenigsberg, DO, MSc, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Neuroradiology, Radiological Society of North America, and Society of NeuroInterventional Surgery
Disclosure: Nothing to disclose.
Pharmacy Editor
Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
CME Editor
Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.
Chief Editor
L Gill Naul, MD, Professor and Head, Department of Radiology, Texas A&M University College of Medicine; Chair, Department of Radiology, Chief, Section of Magnetic Resonance Imaging, Scott and White Memorial Hospital and Clinic
L Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Texas Medical Association
Disclosure: Nothing to disclose.
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