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Subdural Hematom

Asep Aminudin Aziz Pembimbing : DR.dr. M.Z. Arifin . SpBS(K)

Tn. Romlan/73 thn/♂/ 13060729/Trauma/MZ
KU : Penurunan kesadaran AK: ± 2 jam SMRS ketika pasien sedang berjalan didaerah Husein Bandung tiba-tiba pasien tertabrak motor dari arah belakang, sehingga pasien terjatuh dengan kepala membentur aspal. Riwayat pingsan (+), muntah (-), perdarahan telinga, hidung dan mulut (-). Pasien langsung dibawa ke emergensi RSHS Survei Primer A : Clear + C-spine control B : Bentuk dan gerak simetris, VBS kanan = kiri , RR : 20x/menit C : HR : 82x/menit , TD 120/80 mmHg D : GCS : E3M5V2 = 10 Pupil bulat anisokor Ø ODS 3/5mm, RC +/+ Motorik : parese -/Survei Sekunder At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasar subcutis At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis

Rontgen Kepala tidak ada garis fraktur

Head CT Scan (Hasan Sadikin .14-6-2013) .

Head CT Scan : • • • • • • • Soft tissue swelling ar left parietooccipital et left frontal Bone discontinuity (-) Sylfian fissure compressed Sulcy and gyri compressed Hyperdense mass crescent shape at right frontotemporoparietal Ventricle and cysterns are compressed Midline shift > 5 mm to the left .

Thorax x-ray:normal .

0) Craniotomy Evacuation Th/ ICU Ward .5)+ vulnus laceratum at parietooccipital sinistra (S01.0) + Subdural hematome frontotemporoparietal dextra (S06.4 42 13800 193.4 30 1.Lab : Hb HMT Leko Trombo 14.05 WD/ Cedera Kepala Sedang (GCS 10) (S06.000 GDS Na K ur cr 137 138 3.

SDH clot 30 cc. lysis 5 cc.0) + Subdural hematome temporoparietooocipital dextra (S06.Intra Operative Finding : WD/ Cedera Kepala Sedang (GCS 10) (S06. from Bridging vein .Duramater intact.5)+ vulnus laceratum at parietooccipital sinistra (S01. tensed .0) a/r ltemporoparietooccipital dextra: . bluish.GCS pre op : E3M5V2 = 10 .Interval op : 10 hours DO : .

Permasalahan • Bagaimana mekanisme truma pada pasien ini karena pada pemeriksaan fisik ditemukan jejas sebelah kiri sementara pada pemeriksaan CT Scan kesan SDH sebelah kanan ? • Apakah indikasi opersi pada pasien ini ? • Bagaimana prosedur tindakan yang dilakukan bila ditempat pelayanan tidak terdapat CTScan .

PEMBAHASAN .

• Pingsan (+) • Langsung ke RSHS Resume . terjatuh.Anamnesis • ♂/73tahun • ± 2 jam SMRS mengalami kecelakaan lalu lintas. kepala membentur aspal.

4.800 Dx/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome frontotemporoparietal dextra (S06. VL ukuran 3x1x1 cm dasar subcutis • At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis • CT scan kepala : SDH frontotemporoparietal dextra • LAB: Hb: 14. RC +/+ .5)+ vulnus laceratum at parietooccipital sinistra (S01. L. Motorik : parese -/• At l parietal sin: hematome (+).13.0) .Pemeriksaan fisik • GCS : E3M5V2 = 10 Pupil bulat an isokor Ø ODS 3/5mm.

windshield. There are many situations in motor vehicle crashes where the forces are transmitted through the brain without the skull hitting the dashboard. also called a hemorrhage. The brain. the back of the person’s head hits the floor and stops.  Coup/Contrer-Coup Injuries: Related to acceleration-deceleration injuries (e. there is bleeding.g injury to temporal lobe in contralateral temporal trauma) .Mechanism of injury in head trauma ►Direct trauma by compression or crushing ►Acceleration-Deceleration Injuries  Brain has inertia. however. This bleeding causes further damage to the brain.  The skull does not need to strike an object in order for the brain to get injured. when a person falls backwards onto a hard floor. If the brain gets bruised. For example. steering wheel or window. is still moving until it strikes the inside of the skull.

.Subdural Hematoma A subdural hematoma (SDH) is a form of traumatic brain injury in which blood gathers between the dura and the arachnoid.

Subdural Hematoma .

low-pressure venous bleeding of bridging veins (superior cerebral veins) (between the cortex and venous sinuses) dissects the arachnoid away from the dura and layers out along the cerebral convexity • Can be acute. subacute or chronic • CT Scan shows a crescent shaped clot.Subdural hematomas • Occur between the dura and the arachnoid mater. • Typically. It conforms to the shape of the brain and the cranial vault. exhibiting concave inner margins and convex outer margins .

assults. • occur mostly in old patients esp those taking antiplatelet and anticoagulant drugs and with brain atrophy. c) Chronic subdural hematomas • develop over weeks or months. • common in alcoholics (susceptible to falls) • Increased intracranial pressure and cerabral edema are unusual. . • often occur in head trauma from falls and motor vehicle accidents.a) Acute subdural hematomas • most common types of intracranial hematomas. • Associated with compression of the brain and cerebral edema and which increase intracranial pressure • Mortality and morbidity are high b) Subacute subdural hematomas • Take a week for symptoms to develop.

may contain hypodense foci due to serum. CSF or active bleeding . Hyperdense.Acute Subdural Hematoma Crescent shaped.

Diagnosis • Radiographic findings – hyperdense crescent-shaped .

Diagnostic Imaging • Noncontrast head CT scan (imaging study of choice for acute SDH) – The SDH appears as a hyperdense (white) crescentic mass along the inner table of the skull. most commonly over the cerebral convexity in the parietal region. The second most common area is above the tentorium cerebellum .

but rarely associated with skull fracture • Generally loss of consciousness • Any degree or type of coagulopathy should heighten suspicion of SDH • Commonly seen in alcoholics because they’re prone to thrombocytopenia.History • Usually involves moderately severe to severe blunt head trauma • Acute deceleration injury from a fall or motor vehicle accident. and blunt head trauma • Patients on anticoagulants can develop SDH with minimal trauma and warrant a lowered threshold for obtaining a head CT scan . prolonged bleeding times.

Frequency is related directly to the incidence of blunt head trauma -It’s the most common type of intracranial mass lesion. occurring in about a third of those with severe head injuries • Acquire coagulopathies • Anticoagulation therapy • Congenital bleeding disorders • Arteriovenous malformations • Aneurysm rupture .Epidemiology • Trauma .

Mortality/Age • Mortality – Simple SDH (no parenchymal injury) is associated with a mortality rate of about 20% – Complicated SDH (parenchymal injury) is associated with a mortality rate of about 50% • Age – It’s associated with age factors related to the risk of blunt head trauma – More common in people older than 60 years (bridging veins are more easily damaged/falls are more common) – Bilateral SDHs are more common in infants since adhesions existing in the subdural space are absent at birth .

Diagnosis • Clinical manifestations – – – – Headache Nausea Vomiting Alteration of consciousness or neurological status Pupillary dilatation – Focal neurological deficit – Intracranial shift or herniation Note: • For people taking anticoagulants e. the possibility of developing intracranial hematomas from minor head injuries is increased. .g aspirin.

• Small ones require no treatment because the blood is absorbed on its own. memory changes. fluctuating drowsiness. confusion. . paralysis on the side of the body opposite the hematoma.Treatment Subdural hematomas • Symptoms: persistent headache. (a drain is usually inserted and left in place for several days). • Large ones removed by surgery. and speech or language impairment. • monitored closely for recurrences.

Treatment • Surgical evacuation – Indications • Significant mass effect – Thickness of hematoma > 10 mm – Midline shift > 5 mm • Decrease in GCS score by 2 or more • Loss of pupillary reactivity or pupillary dilatation .

time to evacuation. duration of coma. admission GCS score. mechanism of injury. present of coagulopathy . hypoxia or hypotention.Outcomes • Degree of mass effect is more important than Extracerebral mass lesions • Associated factor – age. extent of primary brain injury.

Thank you .

he was brought direcly to Emergency Hasan Sadikin Hospital. nose (+) and mouth (-). vomiting (-).. suddenly he was strucked by motorcycle from behind. when he was walking at Husein area. bleeding from ear (-). Rh -/. VL size 3x1x1 based on subcutis At Left occipital : vulvus laceratum (+) size 5x1x1 cm based on subcutis . Mr Romlan/73 yo/♂/ 13060729/Trauma/MZ CC : decreased of conciousness History : ± 2 hours prior to admission. RR = 20x/m C : BP : 120/90 mmHg PR : 82 x/m D : GCS E3M5V2 = 10 Pupil round unequal Ø ODS 3/5 mm LR +/+ Motoric : no paresis Secondary Survey : At left parietal : hematome (+). he fell down and him head hit the ground. Primary Survey : A : Clear + C-Spine control B : Shape and movement simmetrycal .NP 1. History of unconscious (+).

Head CT Scan (Hasan Sadikin .14-6-2013) .

Head CT Scan : • • • • • • • Soft tissue swelling ar left parietooccipital et left frontal Bone discontinuity (-) Sylfian fissure compressed Sulcy and gyri compressed Hyperdense mass crescent shape at right frontotemporoparietal Ventricle and cysterns are compressed Midline shift > 5 mm to the left .

Thorax x-ray: within normal limit .

0) Craniotomy Evacuation Th/ ICU Ward GCS this morning E3M6V5 = 14 .0) + Subdural hematome at left temporoparietooocipital (S06.05 WD/ moderate Head Injury (GCS 10) (S06.Lab : Hb HMT Leko Trombo 14.5)+ vulnus laceratum at left parietooccipital (S01.4 30 1.000 GDS Na K ur cr 137 138 3.4 42 13800 193.

from Bridging vein .Duramater intact. bluish. tensed .5)+ vulnus laceratum at left parietooccipital (S01.0) + Subdural hematome at left temporoparietooocipital (S06.SDH clot 30 cc.0) Th/ Craniotomy Evacuation DO : a/r left temporoparietooccipital : .Interval op : 10 hours .Intra Operative Finding : WD/ moderate Head Injury (GCS 10) (S06.GCS pre op : E3M5V2 = 10 . lysis 5 cc.