A subdural hematoma (SDH) is a common neurosurgical disorder that often requiressurgical intervention. SDH is a type of intracranial hemorrhage that occurs beneath the dura andmay be associated with other brain injuries. Essentially, it is a collection of blood over thesurface of the brain. SDHs are usually caused by trauma but can be spontaneous or caused by a procedure, such as a lumbar puncture.SDHs are usually characterized based on their size, location, and age (ie, whether theyare acute, subacute, or chronic). These factors, as well as the neurologic and medical condition of the patient, determine the course of treatment and may also influence the outcome.
SDHs are often classified based on the period that has elapsed from the inciting event (if known)to the diagnosis. When the inciting event is unknown, the appearance of the hematoma on CT scan or MRI can help determine when the hematoma occurred.Generally, acute SDHs are less than 72 hours old and are hyperdense compared with the brain onCT scan. Subacute SDHs are 3-20 days old and are isodense or hypodense compared with the brain.Chronic SDHs are 21 days (3 wk) or older and are hypodense compared with the brain. However, SDHsmay be mixed in nature, such as when acute bleeding has occurred into a chronic SDH.
The brain is covered by a membrane (layer of tissue) called the dura. If the veins located below the dura (subdural area) leak blood, then pressure in this area may build up and injure the brain. Head injuries may injure these veins, causing them to be torn and leak. This bloodcollects into a mass called a hematoma.`For the most part, this review discusses acute and chronic SDHs; less information isavailable about the less common subacute SDHs.
The entity of subdural hygroma is brieflyaddressed with chronic SDH.Acute SDH is commonly associated with extensive primary braininjury. In one study, 82% of comatose patients with acute SDH had parenchymal contusions.
The severity of the diffuse parenchymal injury correlates strongly (inverse correlation) with theoutcome of the patient. In recognition of this fact, an SDH that is not associated with anunderlying brain injury is sometimes termed a simple or pure SDH, whereas the termcomplicated has been applied to SDHs in which a significant injury of the underlying brain hasalso been identified.The practice of trephination of the head (ie, chipping or drilling a hole through the skull)has been traced back to ancient times. The author Balzac, in 1840, described a case of chronicsubdural hematoma (SDH), including its traumatic origin and surgical treatment.
In the late 19thcentury, with the rise of medicine, development of aseptic technique and anesthesia, andestablishment of the basic principles of neurologic localization, surgery for intracranial lesions(including SDH) became more common and, later, survival rates improved. In 1883, Hulke firstdescribed successful neurosurgical treatment of chronic SDH.
Although cerebral angiographycould be used to localize SDH in the early–to–mid-20th century, the development of the CT scanin the late 1970s represented another leap in patient care.It is important that a patient receive medical assessment, including a completeneurologicalexamination, after any head trauma. ACT scanor MRI scanwill usually detect
significant subdural hematomas.Treatment of a subdural hematoma depends on its size and rate of growth. Some smallsubdural hematomas can be managed by careful monitoring until the body heals itself. Other small subdural hematomas can be managed by inserting a temporary small catheter through ahole drilled through the skull and sucking out the hematoma; this procedure can be done at the bedside. Large or symptomatic hematomas require acraniotomy, the surgical opening of theskull. A surgeon then opens thedura, removes the blood clotwith suction or irrigation, and
identifies and controls sites of bleeding. Postoperative complications include increased