eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Subdural Hematoma: Differential Diagnoses & Workup
Updated: Oct 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
| Elder Abuse | Stroke, Ischemic |
| Epidural Hematoma | Subarachnoid Hemorrhage |
| Meningitis | |
| Pediatrics, Child Abuse | |
| Stroke, Hemorrhagic |
Other Problems to Be Considered
Dementia
Brain tumor
Subdural empyema
Workup
Laboratory Studies
- Complete blood count
- Coagulation profile
- Electrolytes
- Type and screen/cross
Imaging Studies
- While MRI is superior for demonstrating the size of an acute subdural hematoma (SDH) and its effect on the brain, noncontrast head CT is the primary means of making a diagnosis and suffice for immediate management purposes.
- Acute SDH typically appears on a noncontrast head CT scan as a hyperdense (white) crescentic mass along the inner table of the skull, most commonly over the cerebral convexity in the parietal region (see Media file 1). The second most common area is above the tentorium cerebelli.
Acute subdural hematoma. Note the bright (white) image properties of the blood on this noncontrast cranial CT scan. Note also the midline shift. Image courtesy of J. Stephen Huff, MD.
- Small SDHs may blend in with the adjacent skull and may be appreciated only by adjusting the CT window width to between those generally used to view brain and bone.
- Some degree of midline shift should be present with moderate or large SDHs. Suspect a contralateral mass when midline shift is absent. If midline shift seems excessive, suspect underlying cerebral edema.
- SDHs are relatively uncommon in the posterior fossa since the cerebellum undergoes little movement, which is protective of its bridging cortical veins. SDHs that do occur in that location are usually a result of parenchymal cerebellar injury.
- Interhemispheric SDH causes the falx cerebri to appear thickened and irregular and often is associated with child abuse.1
- In the subacute phase, the lesion becomes isodense (with respect to the brain) and is more difficult to appreciate on a noncontrast head CT scan (see Media file 2).
Subacute subdural hematoma. The crescent-shaped clot is less white than on CT scan of acute subdural hematoma (see Media file 1). In spite of the large clot volume, this patient was awake and ambulatory. Image courtesy of J. Stephen Huff, MD.
- For this reason, either contrast-enhanced CT or MRI is widely recommended for imaging 48-72 hours after head injury.
- On T1-weighted MR images, subacute lesions are hyperdense.
- On contrast-enhanced CT scans, cortical veins over the cerebral surface are opacified and help delineate the lesion.
- Subacute SDHs often become lens-shaped and can be confused with an epidural hematoma.
- In the chronic phase, the lesion becomes hypodense and is easy to appreciate on a noncontrast head CT scan.
- A worsening of the GCS by 2 or more points should prompt repeat imaging in salvageable patients.
More on Subdural Hematoma |
| Overview: Subdural Hematoma |
 Differential Diagnoses & Workup: Subdural Hematoma |
| Treatment & Medication: Subdural Hematoma |
| Follow-up: Subdural Hematoma |
| Multimedia: Subdural Hematoma |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Cohen M, Scheimberg I. Subdural haemorrhage and child maltreatment. Lancet. Apr 4 2009;373(9670):1173; author reply 1173-4. [Medline].
Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery. Jun 2009;64(6):1116-21; discussion 1121-2. [Medline].
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW. Surgical management of acute subdural hematomas. Neurosurgery. Mar 2006;58(3 Suppl):S16-24; discussion Si-iv. [Medline].
Mobbs R, Khong P. Endoscopic-assisted evacuation of subdural collections. J Clin Neurosci. May 2009;16(5):701-4. [Medline].
Narita E, Maruya J, Nishimaki K, Heianna J, Miyauchi T, Nakahata J, et al. [Case of infected subdural hematoma diagnosed by diffusion-weighted imaging]. Brain Nerve. Mar 2009;61(3):319-23. [Medline].
Bell RS, Neal CJ, Lettieri CJ, Armonda RA. Severe Traumatic Brain Injury: Evolution and Current Surgical Management. Medscape. Available at http://cme.medscape.com/viewarticle/575753. Accessed June 24, 2008.
Buntain BL. Craniocerebral injuries. In: Management of Pediatric Trauma. WB Saunders; 1995:177-88.
Eijkenboom M, Gerlach I, Barker A, et al. Chronic cognitive effects of bilateral subdural haematomas in the rat. Neuroscience. 2004;124(3):523-33. [Medline].
Rockswold GL, Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:1142.
Saito T, Kushi H, Makino K, Hayashi N. The risk factors for the occurrence of acute brain swelling in acute subdural hematoma. Acta Neurochir Suppl. 2003;86:351-4. [Medline].
Valadka AB, Narayan RK. Injury to the cranium. In: Trauma. 3rd ed. 1996:267-78.
Wind JJ, Leiphart JW. Images in clinical medicine. Bilateral subacute subdural hematomas. N Engl J Med. Apr 23 2009;360(17):e23. [Medline].
Further Reading
Clinical guidelines
Surgical management of acute subdural hematomas.
Brain Trauma Foundation - Disease Specific Society. 2006 Mar. 9 pages. NGC:005061
ACR Appropriateness Criteria® head trauma.
American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 12 pages. [NGC Update Pending] NGC:005118
Clinical trials
Teen Online Problem Solving (TOPS) - An Online Intervention Following TBI
Internet-Based Treatment for Children With Traumatic Brain Injuries & Their Families: Counselor Assisted Problem Solving (CAPS)
Keywords
subdural hematoma, head trauma, SDH, acute subdural hematoma, subacute subdural hematoma, chronic subdural hematoma, blunt head trauma, head injury, interhemispheric SDH, child abuse
