00:01
So let's talk a little bit
more about subdural hematomas.
00:04
And let's start
with a definition.
00:06
Subdural hemorrhage or subdural hematoma
is a bleeding event into the space
between the dura and arachnoid
meningeal layers surrounding the brain.
00:15
So let's look at that at what's
happening in this schematic.
00:18
And again, we're looking
at the bones and the skull
going down to the
parenchyma of the brain.
00:24
With a subdural hemorrhage,
the problem is in
the subdural space.
00:28
In between the dura and the arachnoid
mater over the surface of the brain.
00:34
Here we see blood layering
over the surface of the brain
in a crescent shape that
extends beyond suture lines.
00:41
And that differs from the imaging
appearance of epidural hematomas.
00:46
In terms of epidemiology,
this is typically found
as a result of head trauma
and 10% of head trauma is
necessitating hospitalization.
00:56
It's found in 20% of severe
traumatic brain injury patients.
01:00
More common in older individuals,
and we'll talk about why that may be
and more common in persons who are on
antiplatelet or anticoagulant therapies.
01:08
And so those are potential risk factors
for the development of a subdural.
01:14
So let's talk
about the etiology.
01:16
Subdural hematomas most commonly
occur as a result of a fall.
01:20
The fall causes injury
to vascular structures
that course between the dura
and the arachnoid layers and
we'll talk about why that is.
01:30
This most commonly exerts forces
in the anteroposterior direction.
01:33
So anteroposterior forces and trauma
lead to injury to the bridging veins
that are in that subarachnoid
and subdural space
and can result in the development
of a subdural hemorrhage.
01:46
And examples of such trauma include motor
vehicle accidents, falls and assaults.
01:52
So let's look at
what's happening,
pathophysiologically, what's causing
the development of a subdural?
So first, let's look at what's happening in
the setting of tearing of bridging veins.
02:02
And here we're looking at a
coronal schematic of the brain.
02:06
We have the bones at the top,
we have this dural
reflection at the sinus
and we see outside of the sinus
extending into the brain of the veins
and they help to drain
the brain of blood supply.
02:19
These bridging veins are
susceptible to tearing
in the setting of
anteroposterior trauma.
02:25
These veins connect the brain
to the superior sagittal sinus.
02:30
They traverse the space in between the
arachnoid and the dural meningeal layers.
02:35
And as a result of
tearing from trauma,
this allows blood to collect in between
those two layers in the subdural space.
02:45
Bleeding may be occluded by
rising intracranial pressure
or direct compression by
the developing thrombus.
02:54
This most commonly is observed
in the temporal parietal regions,
but we can see subdural
hematomas anywhere in the brain.
03:02
We can also see subdural is develop
as a result of arterial rupture,
which is less common but
can be more concerning.
03:08
And again,
we have those arteries extending
between the dural reflections
in the brain itself.
03:14
Small arteries or arterioles
are often less than one diameter
as they coursed through this area.
03:21
They supply blood to the
superficial cerebral cortex.
03:24
They provide the collaterals that help to
collateralize that area of cell bodies.
03:29
They traverse the space between
the arachnoid and the dura
and so they're susceptible to
tearing as a result of trauma.
03:36
And as a result of rupture, we see
blood developing in that subdural space.
03:40
And again, tamponade of bleeding may
occur from rising intracranial pressure
as the blood expands, or by thrombus
compression as it develops in these layers.
03:54
So what's the clinical
presentation of a subdural?
Well, acute subdural
is present immediately,
often within 72 hours
of the traumatic event.
04:03
The initial presentation is either
with focal neurologic deficit or coma
in half of cases.
04:08
And many patients will have slow and
steady progression of symptoms over time,
which differentiates subdural cells
from that epidural hematoma presentation
where we may see
a lucid interval.
04:20
Subacute subdural
s can also occur
as a result of slow
accumulation of blood over time
or with repeated traumas
in elderly patients
where there's particular repeat
tearing up those bridging veins
and may present three to
14 days after the event.
04:35
Subacute subdural is appear as less hyper
dense or with mixed density on the CT.
04:40
And chronic subdural is can
also be a contributing factor
to clinical presentations presenting
more than 15 days after the event.
04:47
And as they're slow expansion
of that blood over time,
this can result in symptoms.
04:51
And typically, this blood will
appear isointense to the brain
and not have that
hyperdense appearance on CT.
04:59
In terms of neurologic symptoms, the nature
of the symptoms like epidural hematomas
depend largely on
four characteristics.
05:06
1. Where is the hematoma?
The patient's symptoms will differ
depending on where the hematoma occurs.
05:11
What is the size?
Larger hematomas are gonna
result in more increases in ICP,
and smaller hematomas may be
asymptomatic or simply affect the cortex
underlying where
the hematoma is.
05:22
The rate of growth will
determine the speed
at which the patient's
neurologic deficits occur
and the acuity of the trauma may also
contribute to the patient's symptoms.
05:30
So we look at all four of
these findings and signs.
05:33
When we're understanding
how we manage the patient
and the symptoms or signs
that they may present with.
05:41
Some of the common symptoms we see
are altered level of consciousness.
05:44
Minor trauma may result in
momentary loss of consciousness
or more severe trauma into coma.
05:50
Subacute and chronic subdural may result
in very gradual deterioration over time.
05:55
We can see headache,
lightheadedness, dizziness,
neck pain or stiffness,
visual changes, nausea,
vomiting from increased ICP balance
or gait dysfunction or dysphagia.
06:05
Pretty much any symptom can
develop in these patients
depending on where the hemorrhage is
and the degree of increase in ICP.
06:12
Other common signs we may see
on exam is nuchal rigidity.
06:16
This blood is in
that subdural space
and we can say some irritation
of the cortical surface
and of the meningeal layer.
06:22
Cranial nerve palsies may
occur, ataxia may develop,
and seizures can occur in some of
these patients, though not all.